Why Health Insurance Still Confuses Everyone – And How to Make Sense of It Understanding Health Insurance & Medical Costs

This information is meant to help guide healthcare decisions. If you are experiencing life-threatening symptoms, seek emergency medical care immediately.

We’ve all been there, you open a medical bill or try to figure out why one doctor is covered but another isn’t, and suddenly you’re lost in a maze of terms like “in-network,” “deductible,” and “co-insurance.”

Even people who work in healthcare admit it’s confusing. Ashley Bellew, Chief of Staff, stated during a recent Cup of Joe discussion, “I’ve never met a person who isn’t confused about insurance, even people that work in hospitals.”

If that sounds familiar, you’re in good company. The good news? Understanding just a few key ideas can help you make more confident, cost-effective choices for your care.

Understanding In-Network vs. Out-of-Network Providers

Let’s start with one of the biggest sources of confusion.

Every insurance company – Blue Cross, Aetna, Cigna, Medicare, and others – creates its own network of healthcare providers. These networks include hospitals, doctors, imaging centers, labs, and more. When a provider is “in-network,” it means they’ve agreed to work with your insurance plan at specific, contracted rates.

Joe Freudenberger, CEO, shared, “In-network means the provider has a contract with your payer. Out-of-network means they don’t.”

That difference can be costly. He explained “My procedure would have cost around $15,000 in-network, but when it was out-of-network, it cost about $60,000.” That’s why checking whether your doctor or facility is in-network before any planned service can make a huge difference in what you end up paying.

How to Choose the Right Facility and Save on Medical Costs

It’s easy to assume that your doctor decides where tests or procedures will be done, but you often have options.

“Most physicians have privileges at multiple locations,” explained Joe. “You can ask for your lab work or MRI to be done somewhere else, as long as it’s in-network with your plan.”

If your doctor orders imaging or lab work, you can request to have it performed at a facility that’s covered by your insurance. Just call your provider or insurer to verify, and ask your doctor’s office to send the order to that preferred location.

These small steps can save you hundreds, or even thousands, without sacrificing quality care. It can also save you quite a bit of time as you are able to choose a location that is more convenient to you than your provider may have suggested.

Freestanding Centers vs. Hospital Care: What Patients Should Know

You’ve probably seen freestanding imaging centers or outpatient surgery facilities around that promise faster service and lower costs. They can be convenient and less expensive, but there are important differences to consider.

“Hospitals are run under tighter standards,” Joe noted. “Everything from equipment to staff training is more strictly overseen.”

That doesn’t mean freestanding centers are unsafe, but hospitals are built for complex care. They have specialized equipment, full-time critical care staff, and the ability to respond if something unexpected happens.

Joe stated, “I tell people all the time, go to hospitals as much as you can, they’re just a safer environment.”

So while outpatient centers might be a good fit for simple, low-risk procedures, hospitals remain the best choice for anything complicated or uncertain.

Why You Receive Multiple Medical Bills, and How to Manage Them

If you’ve ever received multiple bills for one hospital visit, one from the hospital, another from a physician, another from anesthesia, and maybe even one from the lab, you’re not alone in wondering why.

In Texas and many other states, hospitals aren’t allowed to employ most physicians directly. “Each of these providers – anesthesiology, radiology, lab, and so on – are independent businesses,” explained Joe.

That means each group bills separately for its part of your care. It’s complicated, yes, but it’s simply how the healthcare system is structured today.

Behind the Scenes: How Hospitals Negotiate with Insurance Companies

It’s not just patients feeling the pinch, hospitals do, too. Smaller community hospitals often struggle to negotiate fair rates with large insurance companies.

“The bigger, more prestigious the provider, the better the pricing,” Joe said. “Smaller hospitals have less market power, so we sometimes have to appeal to the payer’s compassionate side.”

Despite these challenges, community hospitals continue to fight to stay in-network, because that’s what keeps care affordable for patients. “If we were out-of-network,” he shared, “our patients would face much higher costs, and that’s not in line with our mission to provide affordable care.”

Avoiding Surprise Medical Bills and Understanding Cost Transparency

There’s good news: laws like the federal No Surprises Act now require hospitals to provide patients with a good faith estimate for scheduled procedures. This helps you understand what you might owe ahead of time, avoiding the shock of unexpected bills later.

You can also call your insurance company before any procedure to confirm your coverage, deductible status, and what portion you might be responsible for.

Simple Tips for Navigating Health Insurance with Confidence

Here are a few simple ways to navigate insurance more confidently:

• Verify coverage before scheduling appointments or procedures.
• Request estimates in writing whenever possible.
• Ask questions….your care team and insurance provider can explain options.
• Keep track of your deductible and out-of-pocket maximum.
• Save all your paperwork in case you need to appeal or clarify a bill.

Remember, you don’t have to figure it all out alone. Healthcare teams, patient advocates, and insurance representatives are there to help you understand your coverage and costs.

Health Insurance Doesn’t Have to Be Overwhelming

Health insurance may always have its complexities, but understanding the basics can make the experience far less overwhelming.

Joe summed it up beautifully: “Our mission is to provide affordable care to the very best of our ability. Staying in-network isn’t just a business decision, it’s how we take care of our community.”

When you understand your coverage, ask questions, and choose care wisely, you take a powerful step toward protecting both your health and your peace of mind.

Because at the end of the day, we’re all navigating this together, with care, compassion, and a shared goal: making healthcare make sense.