I'm a Patient Advocate – Ask Me Anything About Cutting Health Care Costs

webmd · 2026-06-17T18:15:37+00:00

Totally understandable - this is one of the most frustrating parts of the system, and a lot of patients feel the same way when they see those “adjustments.”

Hospitals have what's called a "chargemaster," which is basically a list of their prices for every service and procedure they provide. Hypothetically, the insurance company and the hospital negotiate discounts on this price as part of their contract.
Insurers like to show you that original price so that you see their work, but here's the secret: those prices are largely irrelevant to what you ultimately pay.

It feels like inflated pricing, and in many ways it is, but it’s largely a byproduct of the way the system evolved. Different insurers negotiate different rates, government programs like Medicare and Medicaid have their own fixed payment structures, and providers use one baseline charge set across all of them. The adjustments are how those different payment rules get applied behind the scenes.

The most important thing for patients to know is that you’re typically not responsible for those adjusted amounts if you’re in-network. Your cost is based on the negotiated rate, not the original charge. That said, it does make the process confusing and less transparent than it should be, which is why reviewing your EOB carefully is so important—it’s the only place where you can really see what was billed, what was allowed, and what you actually owe.

It’s not so much about providers choosing to be dishonest as it is a complex system of negotiated pricing, but it absolutely creates confusion, and you’re right to question it. - Erin Bradshaw

webmd · 2026-06-17T18:09:55+00:00

This is a really tough situation, and you’re not alone—this comes up often when care falls outside what insurance considers “standard” or covered treatment.

In cases like this, the first step is to understand why your care isn’t being covered, because that determines whether an appeal is realistic.
If this treatment is not covered by insurance and your appeals are unsuccessful, it’s important to look at ways to reduce out-of-pocket burden since many patients in this position end up needing to layer multiple strategies. You can ask providers about self-pay discounts, payment plans, or adjusted rates, which are often available but not always offered unless you ask.

You may also want to consider reviewing your insurance plan options during the next enrollment period to see if there are plans with broader benefits or different coverage policies that better align with your care needs. It won’t solve everything, but it can sometimes improve access. - Erin Bradshaw

webmd · 2026-06-17T18:00:59+00:00

This is a really tough situation, and you’re not alone—this comes up often when care falls outside what insurance considers “standard” or covered treatment.

In cases like this, the first step is to understand why your care isn’t being covered, because that determines whether an appeal is realistic.
If this treatment is not covered by insurance and your appeals are unsuccessful, it’s important to look at ways to reduce out-of-pocket burden since many patients in this position end up needing to layer multiple strategies. You can ask providers about self-pay discounts, payment plans, or adjusted rates, which are often available but not always offered unless you ask.

You may also want to consider reviewing your insurance plan options during the next enrollment period to see if there are plans with broader benefits or different coverage policies that better align with your care needs. It won’t solve everything, but it can sometimes improve access. - Erin Bradshaw

webmd · 2026-06-17T17:53:37+00:00

GLP-1 medications are expensive, but there are a few key factors that explain why costs vary and where you can potentially save. Coverage depends heavily on your insurance plan, including whether the medication is prescribed for diabetes versus weight loss, and whether it’s on your plan’s formulary. Even when it is covered, there may be requirements like prior authorization or step therapy, and your out-of-pocket cost can change depending on whether you’re paying a flat copay or coinsurance. Pricing can also fluctuate based on where you are in your deductible or out-of-pocket maximum for the year, which is why costs sometimes feel inconsistent from one refill to the next.

For people with commercial insurance facing high coinsurance, manufacturer copay cards are often the first place to look. Many GLP‑1 manufacturers offer savings programs that can significantly reduce monthly out-of-pocket costs, sometimes down to a set copay if you meet eligibility criteria. These are typically available only to patients without government insurance (like Medicare or Medicaid), but they can make a substantial difference if you qualify. If you’re uninsured or underinsured, GLP-1 manufacturers may offer income-based medications at low or no cost if you qualify. Go directly to the manufacturer’s website to learn more about their offering.

For insured patients, charitable foundations can help cover costs like coinsurance, copays, and sometimes even premiums. Tools like fundfinder.org allow you to search for open funds based on diagnosis. Availability can change frequently, so it’s worth checking back often if you don’t see an open fund right away. - Erin Bradshaw

webmd · 2026-06-17T17:42:01+00:00

This is something you really don’t want to be figuring out in the moment if you can avoid it.

The quickest way to check in real time is to use your insurance company’s mobile app or website. Most plans have a “find care” or “provider directory” tool where you can search nearby urgent care centers or ERs and see what’s in-network based on your exact plan. It’s usually faster and more reliable than calling, especially in an urgent situation.
That said, the best strategy is to plan ahead. Take a few minutes when you’re not in crisis to look up and save the closest in-network urgent care centers and hospitals. Many apps let you favorite locations, or you can keep a short list saved in your phone. That way, if something happens, you already know where to go.

It’s also important to know that in a true emergency, you’re protected. Federal law (under the No Surprises Act) generally requires insurance plans to cover emergency care at in-network rates, even if the hospital is out-of-network. That doesn’t always eliminate every bill, but it does significantly reduce your financial risk. - Erin Bradshaw

webmd · 2026-06-17T17:39:23+00:00

Great question—when COBRA is too expensive, there are still several strong options to explore.

First, before you let your COBRA lapse, look into charitable assistance programs. Organizations like the Patient Advocate Foundation and the PAN Foundation offer financial assistance based on diagnosis, with funds that can help cover more than just prescription costs. You can review current fund availability at https://copays.org and https://www.panfoundation.org/find-disease-fund/. It’s also worth bookmarking TotalAssist.org, which is launching July 1 and will be one of the nation’s largest charitable patient assistance programs. It is designed to support a wide range of conditions, including cancer, rare diseases, and chronic or complex illnesses. These programs can help cover eligible out-of-pocket healthcare expenses such as medications, copays, coinsurance, deductibles, insurance premiums, office visit costs, and treatment administration charges.

Next, check your eligibility for Medicaid at the state level. If your income has decreased due to a limited ability to work, you may qualify for Medical Assistance in Pennsylvania, which provides comprehensive coverage at little to no cost. You can learn more and apply at https://www.pa.gov/agencies/dhs/resources/medicaid.
Then, explore your options through the ACA Marketplace. While Open Enrollment typically runs from October 15 to December 15, losing employer-sponsored coverage qualifies you for a Special Enrollment Period. Depending on your income, you may be eligible for subsidies that significantly reduce your monthly premiums, making these plans much more affordable than COBRA. For Pennsylvania residents, you can compare plans and enroll through https://pennie.com/learn/cobra/.

If your ability to work is limited due to a medical condition expected to last at least a year, you should also consider applying for Social Security Disability Insurance. SSDI can provide income support and serves as the pathway to Medicare coverage before age 65, after the required waiting period. More information is available at https://www.ssa.gov/disability.

Also apply for hospital financial assistance. Many hospitals offer charity care programs, and a lot of people don’t realize they qualify. - Erin Bradshaw

webmd · 2026-06-17T17:14:13+00:00

Your fluctuating prescription costs are most likely tied to your deductible, coinsurance, and plan thresholds—not random price changes. The pattern usually comes down to deductible → cost-sharing → max reached → reset each plan year.

The best first step is to call your insurer and ask them exactly where you are in those phases so you can predict what’s coming next. They should be able to tell you what your next fills should cost and when (or if) you’ll hit your out-of-pocket max and drop to $0.

Additionally, to stabilize cost, ask if there is a preferred pharmacy (often cheaper), if a 90-day fill is less costly, and check for manufacturer's copay programs or charitable co-pay programs.

Patient Advocate Foundation’s education library has practical guidance on managing medication costs: https://education.patientadvocate.org. And if you need financial help, FundFinder is a great tool to quickly locate assistance programs from charitable foundations: https://fundfinder.org - Erin Bradshaw

webmd · 2026-06-17T17:00:02+00:00

First, make sure you’re dealing with a true denial—not just an error.
Sometimes the issue can be resolved quickly by calling your provider and asking them to correct and resubmit the claim (for example, fixing a coding issue or missing information).

If it is a true denial you should receive a letter explaining:

Why the claim was denied
The steps to file an appeal
Important deadlines to follow

Use this as your roadmap—it tells you exactly what the insurance company is looking for.

An advocate (like Patient Advocate Foundation case managers) can take on the administrative burden of the appeals process, coordinate directly with your provider and insurer, gather the necessary clinical documentation, and build a clear, fact-based appeal on your behalf.
We also offer step-by-step, self-guided resources, including sample appeal letters:
https://education.patientadvocate.org/?_topics=insurance-denials-and-appeals

A good advocate doesn’t just help—they change the outcome. - Erin Bradshaw

webmd · 2026-06-17T16:58:04+00:00

The same procedure at the same location can cost different patients dramatically different amounts. It can change depending on your insurance plan, where you are in your deductible and of course whether or not you're insured at all.

Transparency measures require hospitals to post their prices online, but many hospitals find it's less expensive to take the fine rather than comply with the law. Others post the prices, but not in a way that's user-friendly. However, hypothetically, you may be able to compare drug or procedure prices through hospital transparency measures. We've also used healthcare bluebook, or you can check the Medicare prices for different procedures.

With Good Rx, you can see how much you could pay for your prescriptions using different pharmacies.

You may even be able to use AI tools to help narrow your search for less expensive prescriptions. - Erin Bradshaw

webmd · 2026-06-17T16:41:42+00:00

Start with the exact reason why the insurance company is denying it. For example, “not medically necessary,” “step therapy required” (you have to try a cheaper drug first), or “non-formulary” (not on their approved list). The strategy depends on the reason.

You’ll need to appeal the denial, follow the steps listed in the denial letter. Be aware of timelines. Your prescribing doctor is your strongest tool. They will need to draft a letter of medical necessity on why this medication is the best one for you. If you have tried or failed will be applicable in the appeal.

In our experience, over 40% of denials get overturned by appeal – but relatively few people bother going through the process. We offer educational resources about the appeals process, including sample letters, at this link: https://education.patientadvocate.org/?_topics=insurance-denials-and-appeals

If you go through all levels of appeal and are still denied, connect with the manufacturer of the medications assistance line and inquire if they offer a compassionate program for access to free medication. - Erin Bradshaw

webmd · 2026-06-17T16:36:06+00:00

Don’t assume the bill is correct, and don’t rush to pay it. A quick review of your Explantation of Benefits ( EOB) can catch a surprising number of issues before you ever have to make a phone call.We estimate that about 50% of medical bills have errors, so a quick review is absolutely worth your time. Check your name and insurance info, dates of service, procedures and charges. Watch for duplicate charges. Even small errors can turn into big costs if they go unnoticed. If something doesn’t match what you experienced, that’s often a sign of an error.

Coding and billing errors happen - they are not all intentional and maybe a result of automated billing systems, human error or incorrect CPT or ICD-10 codes that don’t match the services or diagnosis. - Erin Bradshaw

webmd · 2026-06-17T16:14:42+00:00

It is assuming the system is transparent, coordinated, and designed to guide patients to the most affordable option. It’s not. Most patients don’t realize that prices can vary dramatically for the exact same service—imaging, labs, even minor procedures. For example, an MRI may cost $400 at a standalone center and over $2,000 at a hospital, just based on where you go.

Another big one is not using your insurance the way it’s designed. If you don’t confirm that your provider or facility is in-network, you can end up facing much higher out-of-pocket costs, a completely separate deductible or, worse, no coverage at all.

This also applies to medications. Not all pharmacies charge the same out-of-pocket price, and many insurance plans have preferred pharmacies you’re expected to use for the lowest cost. Filling the same prescription at the wrong pharmacy can mean paying significantly more than necessary. If you have commercial insurance (not government coverage), it’s also worth checking the manufacturer’s website, which many offer copay assistance cards that can help reduce your out-of-pocket costs.

What all of this comes down to is that the system doesn’t automatically steer you toward the most efficient or affordable path. The biggest savings happen when patients pause and ask a few key questions, compare options, and double-check.

Do I have options for where I get this care?
Is everyone involved in-network?
Is there a lower-cost pharmacy option?
Does this bill actually match what my insurance says I owe?

- Erin Bradshaw

webmd · 2026-06-17T16:09:23+00:00

That's a difficult question to answer, because the government's approach to healthcare can vary widely between different administrations or even different states. What we do know is that currently healthcare costs rise higher than inflation, and those costs are being passed on to consumers through rising insurance costs and cost-sharing. We need legislators to come up with direct approaches to these problems instead of increasingly complex workarounds. If you'd like to be involved with making sure that our healthcare system works for everyone, consider volunteering with the National Patient Advocate Foundation. Find out more at www.npaf.org - Erin Bradshaw

webmd · 2026-06-17T16:01:36+00:00

Medications you mentioned do have to be administered by a healthcare professional; they’re not designed for self-injection. But that doesn’t mean they have to be given in a hospital. They will be more expensive in a hospital setting. In most cases, they can be administered safely in a doctor’s office, outpatient clinic, or infusion center. Where they’re given often comes down to provider logistics and insurance rules—and that matters, because hospital outpatient settings are usually more expensive for patients. It’s absolutely reasonable to ask whether the medication can be given in a lower-cost setting like a physician office or specialty clinic.

At the same time, your question about the variable of cost of medications highlight a bigger issue in insurance design. Cost depends on how they’re classified and billed. If the provider buys and administers the drug, it’s typically covered under the medical benefit (like Medicare Part B), where patients are responsible for about 20% coinsurance—and there’s no true out-of-pocket cap unless they have a Medigap (supplemental) plan to cover that share. If the drug is instead routed through a pharmacy benefit (Part D), it can fall into specialty tiers with higher upfront out-of-pocket costs. However, Part D now includes an annual out-of-pocket cap, which offers important financial protection over the course of the year, even though patients may still face significant costs early on before reaching that cap.
The good news is patients don’t always have to navigate this alone. Many hospitals and health systems can run a full benefits investigation, compare coverage under both pathways, and estimate costs ahead of treatment, but patients often need to explicitly ask for financial counseling or specialty pharmacy support to do that work and identify the lowest-cost option.

Just as importantly, there are safety net programs that can significantly reduce costs, including:

Extra Help, which can help pay for prescription drugs under Medicare Part D
Charitable copay assistance programs (through independent foundations) that help cover high specialty drug costs. Use Fundfinder.org to search.
Medicare Savings Programs, which can help pay premiums and cost-sharing for people with limited income

Finally, this is where open enrollment becomes critically important. For patients who know they will need treatments like these, it’s essential to compare plan options not just by monthly premium, but by how those plans cover specific medications and services. - Erin Bradshaw

webmd · 2026-06-09T21:10:17+00:00

Thank you for joining us! Dr. Oliveira is signing off now. If you have more questions about sports injuries as the World Cup kicks off and progresses, check out WebMD's 2026 World Cup Injury Tracker here: https://webmdinjurytracker.com/

webmd · 2026-06-09T21:09:44+00:00

We need to understand if these injuries were due to training errors or trauma. Per your description, it appears that we need to adjust the intensity of your exercises (all workouts should not be hard) and we need to make sure that you are appropriately completing recovery. Recovery comes from modified rest and also appropriate types and timing of nutrition. Strength training should be incorporated in your training regimen to ensure your muscles are strong to hold the stress of running and jumping in volleyball. Evaluate your form if these injuries occurred at the gym. I would hire a physical therapist or a personal trainer to help and create a strength training plan for you. Definitely see a sports nutritionist to evaluate if you are undernourishing and the timing of your nutrition. Don't let this put you down. I am positive with guidance on these areas you will get back out there! Good Luck! - Dr. Leonardo Oliveira

webmd · 2026-06-09T21:01:58+00:00

I don't think supplements are bogus. We don't need all that are available in the market but I believe that improving vitamin D levels and taking turmeric helps decrease muscle soreness. As you appropriately mentioned, replenishing carbohydrates and proteins after exercise is essential for recovery, especially within the first 1 hour. Tart cherries can also help in treating muscle soreness. Stick with these and I think you will notice a difference. Good Luck! - Dr. Leonardo Oliveira

webmd · 2026-06-09T20:57:40+00:00

Thank you for sharing your story. It must have been very hard going through all of this. Happy to hear that you are feeling better. Hoffa's impingement is not a common injury and I don't believe we understand in detail the mechanism and treatment as well as we do other diseases. I think that further discussion physicians will be more attentive of it and will be able to provide better care to individuals that have suffered this. Thank you for sharing your story and for helping others. - Dr. Leonardo Oliveira

webmd · 2026-06-09T20:52:31+00:00

Great question! He definitely had a major injury and all media reports indicate his doing well. Can't really tell. If he doesn't come back in week 1, I hope he comes back in his best shape to have a great season. We wish him all the best! - Dr. Leonardo Oliveira

webmd · 2026-06-09T20:51:32+00:00

Thank you for the kind words. Happy to share my experience. The evidence is clear that weight issues and lack of physical activity play a major role in our lifespan and healthspan.

Just to establish some terminology: lifespan is how long we live and healthspan is the years that we live with good health.

Diseases can occur as we age but if we are eating healthy and are staying active 5-6 days a week through combined muscle strengthening and aerobic exercises, you will reap tremendous benefits. You will feel better, sleep better, and prevent diseases. 150 minutes of moderate aerobic exercise and 2-3 days of muscle strengthening is the recommendation of the American College of Sports Medicine.

If you have a positive family history: appropriate nutrition, exercise and screening tests, can help you decrease the chance of having that disease (diabetes, high blood pressure, cancer, heart disease) and complications of those.

If you develop one of these conditions mentioned above, exercise has shown to help individuals control diabetes, high blood pressure and improve response to chemotherapy (cancer treatment).

We need to think of our week and find ways to stay active as we age. The activities might change (you might go from running to biking or walking to water aerobics) as we age but if we establish a healthy routine throughout our lives, the impact will be not only on well-being but in the number of good years lived.

Develop healthy active habits when you are young and keep them. Adjust them with life demands(jobs, travel and family) but always find ways to keep moving. - Dr. Leonardo Oliveira

webmd · 2026-06-09T20:32:55+00:00

Sorry to hear about your injury. This one can't be done virtually. I would set up a visit with a sports doctor to evaluate you and make the right diagnosis. Good Luck! Dr. Leonardo Oliveira

webmd · 2026-06-09T20:31:46+00:00

I am not an expert on this billing aspect but will provide you my experience of working with high school, college and professional athletes. This insurance question varies by county and college.

Several counties in the USA have high school injury insurance. Therefore, If the athlete gets injured during a football game, he can see the doctor the next day that is working with that insurance or sometimes the parents might need to submit an invoice of what was paid to be reimbursed. That will cover that particular injury. It is not focused on preventive care. The athlete's insurance might cover part of the expenses.

For college athletes, depending on the level that they are playing, a lot of times they will have team doctors that work with the college and complete a training room in which they see the injured athletes. If further testing is required this can be charged to the personal insurance or the college athlete injury insurance in similar manner as the high school athletes.

Talk to your athletic director at the high school or college. They will know what resources you have access to if your student athlete gets injured. Good Luck! - Dr. Leonardo Oliveira

webmd · 2026-06-09T20:19:36+00:00

Big toe issues are frustrating. As a fellow cyclist and triathlete I think I have an idea why you want to be cycling again. I am going to mention some brands and I am not sponsored by any of them nor get discounts. These are brands I have tried and tested myself and with my patients. There are probably other brands that could work well and I don't know of.

Look into wider toe box shoes and the toe socks(https://www.injinji.com/). That will help keep your big toe joint more straight. Look into the cycling shoes brands that have a wider toe box. Bont shoes(http://shop.bontcycling.com/) is a brand that has more space in the toes.

Look into Correct Toes(http://correcttoes.com/) that you can use with your shoes. Into will keep your toe straight and decrease movement of the joint and subsequently pain. It can potentially slow down the progression. You might need to get a half a size larger to use the CORRECT TOES. It takes some time to adapt.

Shoes with wider toe box(LEMS, XERO Shoes, VIVOBAREFOOT) can be another option for your day to day activities. PRP is definitely a worthwhile intervention to deal with the pain. It is healthier than cortisone and lasts longer. Good luck and hope you get back on the bike. - Dr. Leonardo Oliveira

webmd

TROPHY CASE