Jane Dotson
Medical billing is a complex and confusing process, and it's not uncommon for patients to be overcharged or receive inaccurate bills. If you find yourself in this situation, there are steps you can take to dispute the charges. It's important to know your rights and protections when it comes to medical bills and collections, and there are resources available to help you navigate the process. This includes understanding the No Surprises Act, which protects consumers from certain unexpected medical bills. If you have insurance and receive a bill that you believe should be covered, there are specific actions you can take to resolve the issue.
| Characteristics | Values |
|---|---|
| When to dispute a medical bill | When the billed amount is $400 or more above the estimate |
| Who can dispute a medical bill | Patients, providers, or insurers |
| What to do before disputing a medical bill | Ask your provider for a plain language explanation for unclear items on the bill, ask debt collectors to verify the debt, research other prices to use for negotiation |
| How to dispute a medical bill | Submit a dispute through the Independent Dispute Resolution (IDR) process, call or write to the hospital, call your insurer's customer service line, contact the National Association of Insurance Commissioners, call your employer's head of Human Resource department |
| What to do if the dispute is decided in your favor | Your provider must reduce your bill by at least $12.50 (half of the $25 administrative fee) |
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What You'll Learn
Ask for a good faith estimate before receiving care
It is within your rights to request a good faith estimate of the cost of your care before receiving it. This is especially important if you are uninsured, as medical bills are the most common item on people's credit reports and can result in reduced access to credit, increased risk of bankruptcy, and avoidance of medical care.
A good faith estimate is an estimate of the amount you will be billed for scheduled items or services, or non-emergency items or services upon request. It should include the costs of items and services anticipated with your visit, such as medical tests and hospital fees. You can request this estimate from your healthcare provider, and any other providers you choose, before scheduling an item or service. If you are scheduled for surgery, it is recommended that you request two good faith estimates: one from the surgeon and one from the hospital. You can ask for this estimate to be provided to you in writing, via email, or on paper.
If you are uninsured, your healthcare provider is required to give you a good faith estimate. If you are insured, you can still request a good faith estimate, but it is not guaranteed that your provider will give you one. If you do not receive a good faith estimate and are later billed for an amount $400 or more above what you expected, you may be able to dispute the charges through the patient-provider dispute resolution process.
To ensure you receive an accurate good faith estimate, schedule your care at least three business days in advance. This will allow your provider enough time to provide you with an estimate and ensure that you are not unexpectedly billed for emergency services from an out-of-network provider.
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Understand your rights and protections
Understanding your rights and protections is crucial when disputing a medical bill with insurance. Here are some key points to keep in mind:
Firstly, if you have insurance, carefully review your insurance policy and benefits explanation (EOB) to understand what services are covered and to what extent. This will help you identify any discrepancies or unexpected charges. If there is a mismatch between what is covered in your policy and what you are being billed for, you may have grounds for a dispute.
Secondly, be aware of the No Surprises Act, which offers protections against certain unexpected medical bills. For treatments received on or after January 1, 2022, you should not receive surprise bills for emergency services from out-of-network providers. If you receive care from an in-network facility, you should not be charged more than in-network rates. If your provider failed to inform you about potential costs in advance, or if you receive unexpected bills from out-of-network providers, you may have a valid dispute.
Thirdly, if you did not use your insurance for a particular treatment, you have the right to receive a “good faith” estimate of the costs before receiving care. If the final bill exceeds the estimate by $400 or more, you may be eligible to dispute the charges through the patient-provider dispute resolution process. This process involves an independent third party reviewing your bill and determining an appropriate payment. Remember that you must have informed your provider beforehand that you would not be using insurance.
Additionally, be cautious of debt collectors and credit reporting practices. Debt collectors are required to first attempt to collect the debt from you before reporting it to credit companies. You have the right to dispute any information reported and to request verification of the debt. Avoid individuals or services that promise to keep medical bills off your credit report or protect you from unexpected costs, especially if they charge upfront fees. Instead, seek reputable credit counselors who are transparent about their services and fees.
Lastly, remember that you have the right to negotiate with your healthcare provider. If you are unable to afford the bill, communicate this to your provider, as they may be willing to reduce the charges or work out a payment plan. Nonprofit hospitals are legally required to offer financial assistance programs. You can also research the prices of similar treatments at other hospitals or use tools like Healthcare Bluebook to gather information for negotiation.
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Research and negotiate with price comparisons
Researching and negotiating with price comparisons is a key step in disputing a medical bill with insurance. This involves several important considerations and actions:
Firstly, it is crucial to understand your insurance coverage thoroughly. Log in to your insurer's website and carefully review your plan details, including your explanation of benefits (EOB). The EOB outlines the costs of your services, how much your insurance covers, and your expected out-of-pocket expenses. Compare your EOB with your medical bill to ensure the charges match and identify any discrepancies.
Next, research the average costs of the procedures and services you received in your state or area. Utilize resources such as Healthcare Bluebook, Healthcare Cost and Utilization Project, or Fair Health Consumer to find this information. Compare these average costs with the charges on your medical bill to determine if you are being overcharged.
If you identify discrepancies or have questions about your coverage, contact your insurer for clarification. Be prepared for potential challenges in reaching them by phone, as it is in their financial interest to make this process difficult. However, persevere as it is worth clarifying any uncertainties.
Additionally, consider reaching out to your medical provider for their estimated costs for the treatments you require. You can then present this information to your insurance company to gain a clearer understanding of how much your health plan will cover and what you will need to pay out-of-pocket.
If you are uninsured, you can still negotiate. Determine what price an insurance company might negotiate for the service you received, and then politely request that your healthcare provider honours that price.
Remember, billing errors are common, so scrutinize your medical bill for any mistakes or duplicate charges. If you find any errors, document them and contact your provider's billing department to have them corrected.
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File a dispute through the Independent Dispute Resolution (IDR) process
If you are facing issues with your medical bill and want to dispute it with your insurance, you can consider filing a dispute through the Independent Dispute Resolution (IDR) process. The IDR process is designed to resolve payment disputes between healthcare providers and health plans, ensuring an impartial decision on fair payment without burdening the patient. Here's a step-by-step guide on how to navigate this process:
Understanding the IDR Process:
The Independent Dispute Resolution (IDR) process is facilitated by the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury. It serves as a mechanism to determine payment rates for certain out-of-network charges. Before initiating the IDR process, it's important to note that there is a required 30-business-day open negotiation period. During this time, both parties should attempt to reach an agreement on a payment amount. If no consensus is reached within this timeframe, either party can then proceed with the IDR process.
Selecting a Certified IDR Entity:
In the IDR process, a certified IDR entity acts as a neutral third party to resolve the dispute. This entity is selected from a list of certified organizations, ensuring they have no conflicts of interest with either party. Both the provider and the health plan propose their payment offers, and the IDR entity makes an impartial decision by choosing one of the proposed payment offers. It is important to note that both parties must agree to the selection of the IDR entity and attest to having no conflicts of interest.
Initiating the IDR Process:
To initiate the IDR process, the initiating party selects an IDR entity from a dropdown menu on the CMS Portal. The non-initiating party can either agree or disagree with the selected IDR entity. If both parties cannot reach an agreement on an IDR entity within 3 days, the Departments will randomly assign an IDR entity from the remaining eligible options. Once the IDR entity is assigned, both parties will receive an email notification.
Submitting Offers and Supporting Documentation:
After the IDR entity has been assigned, both the provider and the health plan must submit their payment offers and additional information to support their proposed offers. It is important to provide comprehensive documentation to strengthen each party's position. The IDR entity will carefully consider the offers and supporting evidence before making a decision.
Resolution and Payment:
The certified IDR entity will review the submitted offers and supporting documentation from both parties. They will then make a determination by selecting one of the proposed payment offers. This decision is final, and both parties must abide by it. Once the dispute is resolved, FHAS and the Departments will notify the parties via email. The payment must be made within 30 calendar days of the resolution.
Remember, the IDR process is designed to provide an impartial resolution to payment disputes. It is important to follow the outlined steps, provide accurate information, and meet the required deadlines to ensure a smooth and efficient dispute resolution process.
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Contact your insurer's customer service line
If you have received a medical bill that you think is incorrect, you can contact your insurer's customer service line. This is a good first step to clarify any discrepancies and understand your health plan's coverage.
When you call, be prepared with all the relevant information, such as your policy number, the date of service, and details of the treatment or procedure. It is also a good idea to have the bill in front of you so you can ask questions about specific charges. Ask for a detailed explanation of the bill and confirm whether the charges are correct. If there are any errors, make a note of them, and ask about the process for correcting them.
It is important to remain calm and polite during the call. Explain your situation clearly and ask about your options for disputing the charges. The customer service representative may be able to help you understand your coverage and whether the service or procedure should be covered by your health plan. They may also be able to help you understand any exclusions or limitations that apply.
If the bill is for a surprise or emergency service, be sure to mention this. You may have additional protections under the No Surprises Act, which protects consumers from certain unexpected medical bills. For example, if you received treatment from an out-of-network provider at an in-network hospital, you may only be responsible for your in-network copayment, coinsurance, or deductible. In such cases, your insurer may need to dispute the charges on your behalf or initiate an independent dispute resolution (IDR) process.
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Frequently asked questions
If your health plan isn't covering something that you thought would be covered, call your insurer's customer service line.
Contact the National Association of Insurance Commissioners. You can also contact your state and file an appeal.
You can ask your Human Resources Department to advocate on your behalf.
You can write a letter or email to the hospital's CEO and CFO. You can also contact the hospital's board members through their offsite office and inform them of the hospital's predatory billing practices.
