Alyssa Lane
Medical bills can be a confusing and unclear space, with patients sometimes finding themselves caught between their medical providers and their insurance company. With the cost of healthcare ever-increasing, it is important to know your rights when it comes to disputing a medical bill. There are several reasons why you might want to dispute a medical bill, including unexpected out-of-network charges, coding errors, or incorrect calculations. Whether you choose to argue your medical bill with your insurance company or directly with the clinic will depend on the specific circumstances of your case.
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What You'll Learn
- The No Surprises Act: A federal law that protects against unexpected out-of-network medical bills
- Reviewing itemized bills: Check for double charges, coding errors, and incorrect calculations
- Good faith estimates: Providers must give cost estimates if you don't use insurance, and you can dispute bills over $400 more than the estimate
- Debt collection rights: Debt collectors must attempt to collect a debt from you before reporting it to credit agencies, and you have the right to dispute it
- Negotiating bills: If you can't pay, you can negotiate with providers, ask for discounts, and explore financial assistance programs
The No Surprises Act: A federal law that protects against unexpected out-of-network medical bills
The No Surprises Act is a federal law that came into effect on January 1, 2022. It applies to most types of health insurance and protects consumers from unexpected out-of-network medical bills.
Before the No Surprises Act, if you had health insurance and received care from an out-of-network provider or facility, your health plan might not have covered the entire out-of-network cost. This could result in higher costs than if you had received care from an in-network provider or facility. In addition to any out-of-network cost-sharing, the out-of-network provider could bill you for the difference between the billed charge and the amount your health plan paid, unless banned by state law. This is called "balance billing".
The No Surprises Act creates a "floor" for consumer protections against surprise bills from out-of-network providers and related higher cost-sharing responsibilities for patients. It bans surprise bills for most emergency services, even if you receive them out-of-network and without prior authorization. It also bans out-of-network cost-sharing for most emergency and some non-emergency services, as well as out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) provided by out-of-network providers as part of a patient's visit to an in-network facility.
The Act also requires health care providers and facilities to give you an easy-to-understand notice explaining the applicable billing protections and who to contact if you have concerns. If you are insured and your health plan denies all or part of a claim for service, you can appeal that decision. Your plan documents will contain information on the review process and how to request a review of your plan's decision.
In addition, the Act outlines a process for your insurance company and the provider to settle disputes over the provider's charges, ensuring a fair resolution. This process starts with negotiations between plans and providers, and if negotiations don't succeed, an independent dispute resolution (IDR) process is followed. Federal agencies have published regulations and rules to implement the law.
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Reviewing itemized bills: Check for double charges, coding errors, and incorrect calculations
Medical bills can be complex and confusing, but reviewing them for accuracy is important and may help you save money. Here are some steps to take when reviewing an itemized bill to check for double charges, coding errors, and incorrect calculations:
Request an Itemized Bill
You have the right to request a list of the costs for each medical item or service you are being billed for. This will allow you to review the charges in detail and identify any discrepancies.
Check for Double Charges
Double billing, or charging for the same service or procedure multiple times, is a common issue in medical billing. Review your bill for any duplicate charges, especially if you received care from multiple providers or had multiple visits for the same issue. If you suspect double billing, contact the billing department of each provider to clarify the charges.
Verify Billing Codes
Each item on your medical bill should have a corresponding billing code. Look up the medical billing code for each item on your bill and read the descriptions. Compare these descriptions to the care you received. If the billing codes do not match the treatments or services you received, there may be a coding error, and you should contact the provider's billing department.
Calculate Totals
Check the math on your bill to ensure that the totals are correct and that you are being charged the correct amount for each item. Calculate the sub-totals and grand total yourself to verify that there are no incorrect calculations.
Review Insurance Coverage
If you have health insurance, make sure to understand your coverage and what is included in your plan. Compare the amounts covered by your insurance to the amounts listed on your bill. If there are discrepancies, contact your insurance provider for clarification.
Remember that medical billing can be complicated, and you have the right to seek assistance. You can reach out to patient advocates or Consumer Assistance Programs in your state for help with billing issues. Additionally, you can submit a complaint if you believe your provider or insurer is not following the appropriate rules regarding billing and insurance coverage.
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Good faith estimates: Providers must give cost estimates if you don't use insurance, and you can dispute bills over $400 more than the estimate
If you don't have health insurance or choose not to use it for a procedure, you are entitled to a good faith estimate of expected charges. This is a federal law that came into effect on January 1, 2022, as part of the No Surprises Act. The Act protects patients from unexpected out-of-network medical bills.
To receive a good faith estimate, you can request one or schedule services at least three business days in advance. You can expect to receive the estimate within one business day of scheduling if your appointment is between three and ten days in advance. If your appointment is scheduled more than ten days ahead, you should receive the estimate within three business days. You can also request an estimate without scheduling an appointment, and the provider is required to provide it.
A good faith estimate should include expected charges for the scheduled healthcare items and services, including facility fees, hospital fees, and room and board provided by the provider or facility. It is not a bill, so the actual cost may differ, but you can dispute any amount that is more than $400 over the estimate.
If you wish to dispute a bill, an independent third party will review it and determine an appropriate payment. To initiate the dispute, you must pay a $25 fee, which will be deducted from your final medical bill if you win the dispute. You can only dispute bills dated within the last 120 calendar days (about four months).
If you used health insurance, you do not qualify to dispute a bill. However, you can submit a complaint if you received an out-of-network bill for a visit to the emergency room or an in-network facility, or if you paid more than in-network rates.
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Debt collection rights: Debt collectors must attempt to collect a debt from you before reporting it to credit agencies, and you have the right to dispute it
When faced with unexpected medical bills, it's important to understand your rights and options for disputing them. Here are some detailed paragraphs on debt collection rights and the steps you can take to argue a medical bill:
Understanding Your Debt Collection Rights
The Fair Debt Collection Practices Act (FDCPA) protects your rights when it comes to debt collection practices. This federal law prohibits debt collectors from employing abusive, unfair, or deceptive tactics when attempting to collect debts from you. It covers various types of debts, including credit card debt, car loans, medical bills, student loans, and mortgages. Under the FDCPA, debt collectors must follow certain rules, such as limitations on how and when they can contact you. For instance, they can't call you more than seven times within a seven-day period. Additionally, if you don't recognize a debt or believe you don't owe it, you have the right to dispute it.
Disputing a Medical Bill
If you receive a medical bill that you believe is incorrect or unfair, there are several steps you can take to dispute it:
- Review your bill in detail: Go through the itemized bill line by line. Look for any discrepancies, double charges, coding mistakes, or incorrect calculations. Compare the charges with your health insurance plan to understand what you're responsible for paying versus what your insurance covers.
- Gather relevant information: Obtain your medical records and any letters or documentation from your doctor that supports your case, especially if they disagree with the insurer's denial of coverage.
- Communicate with your insurance provider: Contact your insurance company and discuss the issues with your bill. If they should be covering specific expenses, ask your doctor for a letter explaining their disagreement with the insurer's decision.
- File an appeal: If you're certain that your insurance company should be covering the bill or reimbursing you, file an appeal within the specified timeframe, which is often 30 to 60 days.
- Involve a third-party reviewer: If your appeal is denied, consider seeking help from a medical advocacy agency that can work with your insurance company and doctor to find a solution. They can assist in negotiating discounts or financial assistance programs.
- Dispute the bill formally: If you still disagree with the bill, you can initiate a formal dispute process. This typically involves paying a fee (which may be refunded if the dispute is resolved in your favor) and providing supporting documentation. An independent third party will then review your bill and determine an appropriate payment amount.
Remember, it's important to act promptly when dealing with medical bills to avoid potential harm to your credit score. Keep detailed records of all communications and be proactive in seeking resolutions.
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Negotiating bills: If you can't pay, you can negotiate with providers, ask for discounts, and explore financial assistance programs
Negotiating medical bills can be a daunting task, but there are several strategies you can employ if you find yourself unable to pay. Firstly, it is crucial to review your bill for any discrepancies or errors. Request an itemized bill, which lists every charge, and compare it against your health insurance plan to identify what you are responsible for paying versus what your insurance covers. Look for double charges, coding mistakes, and incorrect calculations. Additionally, ensure that you received an Explanation of Benefits (EOB) report from your insurance provider, detailing what they have covered for that specific date and healthcare visit.
If you identify any issues with your bill, contact the billing office and request them to recode and re-bill your insurer. You can also consult your insurer directly, as they may fix errors and provide a copy of your EOB. It is important to act promptly, as most providers have a 60- to 90-day window for bill payment before it gets sent to a collections agency, which can negatively impact your credit score.
If you are still facing difficulties paying your bill, you can negotiate with the medical provider. Many hospitals are accustomed to negotiating and may be willing to offer a reduced fee or a more affordable payment plan. Some providers may even offer immediate discounts of up to 20% if you agree to pay the discounted total right away. You can also explore financial assistance programs, often called "Charity Care," which provide free or discounted healthcare to those struggling financially. These programs are mandated by federal and state laws for hospitals and health systems offering medically necessary services. Nonprofit hospitals, under the Affordable Care Act (ACA), must have written policies outlining eligibility criteria for financial assistance. Remember that negotiating without insurance can be more complex, so arm yourself with research when contacting the hospital billing department.
If you have health insurance, the No Surprises Act (NSA), effective January 1, 2022, offers protection from "surprise billing" for both insured and uninsured individuals. It safeguards against unexpected out-of-network medical bills and certain practices, such as requiring you to pay out-of-network charges for emergency services. If you believe your facility, provider, or insurer is not adhering to these rules, you can submit a complaint or call for assistance.
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Frequently asked questions
First, check if the bill is illegal under the No Surprises Act, a federal law that protects consumers from certain unexpected medical bills. If you received a bill for emergency services from an out-of-network provider that you were not aware of, you should not be billed for more than your usual in-network charges.
Review your itemized bill line by line, looking for double charges, coding mistakes, and incorrect calculations. Compare these charges with your health insurance plan to determine which charges you are responsible for and which your insurance company should cover. If you notice any discrepancies, contact your insurance company and request that they investigate the issue.
Ask your doctor for a letter explaining why they disagree with the insurer's denial decision. Include this letter, along with your medical records and other relevant information, when filing an appeal with your insurance company. Act quickly, as appeals typically need to be filed within 30 to 60 days.
Contact a medical advocacy agency, which can work with your insurance company or doctor to find a solution. If you are unable to resolve the issue and must pay the bill, you may be able to negotiate a discount by providing proof of financial hardship. Nonprofit hospitals are required by law to offer financial assistance programs, and many other providers are willing to arrange payment plans.
