En español | Disputing a problem on a medical bill can be time-consuming and frustrating. “It takes our professional case managers on average 22 calls to resolve a case,” says Caitlin Donovan, spokesperson for the nonprofit Patient Advocate Foundation.
While most disputes aren’t as complicated as the ones Donovan’s organization takes on, you should be prepared for a lengthy battle. The medical billing system is extremely complicated, with thousands of codes representing the universe of treatments and procedures. The range of possible problems is vast, from coding mistakes and duplicate charges to surprise out-of-network fees and wrongly denied insurance claims.
No matter what kind of billing problem you face, follow these recommendations to boost your chances of getting an overcharge removed or an insurance denial reversed.
Get the itemized bill
Hospitals and medical offices often send a bill that summarizes the services you received and lists one lump sum due. To spot problems, ask for an itemized statement.
“You want to see every single charge that they charged you,” says Teresa Brown, senior director of hospital accounts at Medliminal, a company that works with insurers, medical offices and consumers to review bills and lower health care costs. “That is your first line of defense.”
Check to see if you are being charged for services you didn't receive, medications you didn't take or facilities you didn’t use. Compare the bill with the explanation of benefits (EOB) sent by your insurance company or, if you’re a Medicare recipient, your Medicare Summary Notice.
Talk to your medical provider
Ask your doctor’s office about any charges you don’t understand, point out any obvious errors and request that they review your bill.
If you are challenging a charge, ask the medical provider to hold off sending the bill to collections while you seek a resolution. You can do this with a phone call, but if your issue is complicated and will likely take a while to settle, it’s a good idea to get the hold agreement in writing, says Beth Morgan, president of Medical Bill Consultants, a company that helps consumers dispute incorrect health care bills. (Learn how to negotiate with a medical provider over your bill.)
Contact your insurer
If your health plan isn’t covering something you thought would be covered, call the customer service line and ask directly, “What needs to happen for this to be covered?” Donovan suggests. The insurer may be missing a key medical record indicating a service was necessary, or the service may have been provided by an out-of-network doctor.
Sometimes, it’s just a matter of the medical provider entering the wrong code when it submitted your claim. Ask your insurer for help in setting the record straight. “Many insurance companies have finally started to realize that they need to offer value-added services to the customer and, therefore, have started offering claim-resolution services,” says Ingrid C. Lindberg, a former Cigna executive and the founder of Chief Customer, a customer service consulting firm.
Starting with your first phone call, write down the date and time, the name of every person you talk to and the information they share. “That way, you can always go back and see where you got each piece of information,” Morgan says.
Often, the first person you’ll talk to in a billing dispute works at an offshore call center and doesn’t have the authority to adjust your bill, she adds. If you aren’t getting anywhere with that person, ask to speak to a supervisor. If you hit another brick wall, ask for that person’s supervisor.
It might take several conversations with your insurance company and the doctor's billing office to resolve the issue. For each one, get the information and documents you need to make the case that you were billed in error. For example, search online for the five-digit codes that correspond to each charge on your bill and make sure they reflect the services provided or procedures performed.
Consider requesting your medical record and reviewing the doctors’ and nurses’ notes, recommends Pat Palmer, chief executive officer of Beacon HCI, which helps companies identify medical billing errors and reduce health care costs. If you had surgery, check how long you were actually in the operating room. Most hospitals charge by the minute, and getting that time right can shave hundreds of dollars off your bill.
If your only issue with your bill is that the amount seems outrageous, it’s still important to collect evidence. Online cost-comparison tools from FAIR Health and Healthcare Bluebook give you an estimate of typical charges in your area for specific procedures.
File an insurance appeal
If your health plan ultimately denies a claim for treatment, you have the right to appeal. Enlist your doctor’s help: He or she can write a letter supporting your case and provide documentation, such as journal articles, to support why a certain procedure or treatment was medically necessary.
You can file an appeal up to 180 days after you are notified of a denial. The explanation of benefits (EOB) you get from your insurance company will have information about how to file. If you do, your insurer must do what the U.S. Department of Health and Human Services calls a "full and fair review" of its initial rejection. If you lose here, you can request an "external review" by an independent organization accredited to review health care decisions.
The Patient Advocate Foundation has a downloadable guide with detailed advice on navigating this process, including sample appeal letters and a checklist of evidence to gather. If you have Medicare, the nonprofit Medicare Rights Center can walk you through appealing a denial.
Check to see if the medical provider has a patient advocate — many hospitals do — and reach out to him or her.
If your dispute is over insurance coverage, contact your state’s insurance commission. “This is the agency in charge of making sure insurance providers comply with the law,” Palmer says. “They may offer to contact both the provider and the insurance company on your behalf.”
For a fee, a medical billing advocate may be able to help correct errors or negotiate with providers. They may charge by the hour, or work for a percentage of the money they save you. You can look for advocates on the websites of professional membership groups such as the Alliance of Professional Health Advocates, the National Association of Healthcare Advocacy and the Alliance of Claims Assistance Professionals.
If you aren’t able to get a bill revised or a denial of coverage overturned, ask the medical provider’s billing office to reduce what you owe.
“A lot of times, you can negotiate a lower, one-time payment because providers know that’s better than dragging it out or not being paid at all,” says Cyndee Weston, executive director of the American Medical Billing Association. “Try saying, ‘I will pay it right now if you drop it to this amount,’ and start with about half of the bill.”
Many medical offices also offer interest-free payment plans, and most hospitals have some kind of financial assistance program based on income.
AARP’s Money Map can help you take control of unplanned expenses and get you on back on track to financial stability.