Haris Ashley
Medical bills are often complicated and hard to understand. If you're insured, the law bans certain practices, like making you pay out-of-network charges for emergency services. However, if your healthcare provider is out-of-network, you may still receive medical bills after insurance pays its portion of your costs. If you receive a surprise medical bill, you can take action by contacting the No Surprises Help Desk. You can also submit a complaint if your provider didn't give you a good faith estimate of the costs. If you're unsure about a charge, talk to the accounting or billing office of your provider and then reach out to your insurance company to try to rectify any errors.
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What You'll Learn
Understand your rights with insurance
Understanding your rights with insurance is crucial, especially when it comes to medical bills. Here are some key points to be aware of:
The Patient Bill of Rights: This was designed to give patients protections when dealing with health insurance companies, particularly in the context of private health insurance. The Patient Bill of Rights helps patients take an active role in their health care, make informed decisions, and understand their rights regarding health coverage and payment of services. It's important to note that this may not apply to plans issued before September 23, 2010, as those are "grandfathered" and exempt from these rules. Check with your insurance plan to see if they have a Patient Bill of Rights for you to review.
The No Surprises Act: This federal law, which came into effect on January 1, 2022, protects individuals with most types of health insurance from unexpected out-of-network medical bills. It applies to emergency services, non-emergency care related to visits to in-network facilities, and post-stabilization services in most cases. If you receive a surprise bill, you can submit a complaint to the No Surprises Help Desk and follow the dispute process.
Protections for Pre-existing Conditions: Under the Affordable Care Act (ACA), insurance companies cannot deny coverage or charge more to individuals with pre-existing health conditions. Additionally, insurance plans cannot set yearly or lifetime limits on essential services, such as doctor visits, emergency services, hospitalization, and prescriptions.
Right to a Good Faith Estimate: If you don't have or use health insurance, providers must give you a good faith estimate of the cost of your care if you request one or schedule services in advance. You may be able to dispute your bill if it exceeds the estimate by at least $400.
Cost-sharing: When using insurance to pay for medical services, you may be responsible for a portion of the cost through cost-sharing, which can take the form of copayments, deductibles, or coinsurance. It's important to understand what your insurance plan covers and what costs you may be responsible for.
By knowing your rights with insurance, you can better navigate the complex world of medical billing and dispute unexpected or unfair charges. Remember to review your insurance plan's documents and stay informed about your specific rights and protections.
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Learn about surprise medical bills
Surprise medical bills are unexpected bills for medical services. They often occur after an accident or sudden illness, and consumers are rarely informed of the costs of medical treatment before receiving emergency treatment.
The No Surprises Act, which came into effect on January 1, 2022, protects people covered under group and individual health plans from receiving surprise medical bills. This federal law applies to most types of health insurance and protects consumers from unexpected out-of-network medical bills. It also establishes an independent dispute resolution process for payment disputes between plans and providers.
Under the No Surprises Act, if you have coverage through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE, you are already protected against surprise medical bills from providers and facilities that participate in these programs. Additionally, if you receive care in an emergency room, you are protected from unexpected out-of-network charges for emergency medical services in most cases.
If you believe you have received a surprise medical bill, you can take action by contacting the No Surprises Help Desk at 1-800-985-3059 or the Consumer Financial Protection Bureau at 1-855-411-2372. You can also submit a complaint if you believe your provider isn't following the No Surprises Act or if they didn't give you a good faith estimate of the cost of care. To dispute a bill, you may need to pay a $25 non-refundable administrative fee.
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Know when you can dispute a bill
Knowing when you can dispute a medical bill is an important aspect of managing your finances. Here are some scenarios where you may be able to dispute a medical bill:
Surprise or Emergency Bills:
If you receive a surprise bill, which is an unexpected out-of-network charge at an in-network hospital, you may be able to dispute it. Federal laws, such as the No Surprises Act, protect individuals from certain surprise bills, especially in emergency situations. If you have health insurance, check your explanation of benefits (EOB) to determine if the service or procedure is covered. If it is, and your insurance company is refusing to pay, contact the National Association of Insurance Commissioners or your state to file an appeal.
Good Faith Estimate Discrepancy:
If you received care on or after January 1, 2022, and your provider charged at least $400 more than their good faith estimate, you may be eligible to dispute the bill through the patient-provider dispute resolution process. A good faith estimate is an expected charge estimate provided by your healthcare provider before scheduled care.
Unnecessary or Avoidable Care:
If you received unnecessary care or experienced avoidable complications, you can dispute the charges and demand not to be billed for those services.
Billing Errors and Unfair Charges:
Before disputing a bill, carefully review it for any errors or unfair charges. If you identify any discrepancies or incorrect charges, you can contact the hospital's administration or billing department to correct the errors.
Non-Compliance with Notice and Consent Rules:
If your provider did not follow the rules regarding notice and consent, you can submit a complaint or dispute the bill. For example, providers are not allowed to ask you to sign a notice and consent form for emergency services.
It is important to note that the specific rules and processes for disputing medical bills may vary depending on your location and insurance plan. Always review your insurance plan documents and consult official sources for the most accurate and up-to-date information.
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Understand the No Surprises Act
The No Surprises Act is a federal law that came into effect on January 1, 2022, to protect consumers from surprise medical bills. The Act applies to most types of health insurance and offers protection from unexpected out-of-network medical bills in the following scenarios:
- Most emergency services, even if received out-of-network and without prior approval.
- Non-emergency services from out-of-network providers at in-network facilities.
- Services from out-of-network air ambulance service providers.
The Act also establishes an independent dispute resolution process for payment disputes between plans and providers. It provides new dispute resolution opportunities for the uninsured and self-pay individuals when they receive a medical bill that is significantly higher than the good faith estimate provided by the provider.
Under the No Surprises Act, health plans must treat out-of-network services as if they were in-network when calculating patient cost-sharing. This means that patients will no longer be at risk of large surprise out-of-network bills when receiving emergency care or elective procedures. In the case of a surprise out-of-network service, health plans are required to make an initial payment to the provider or transmit a notice of denial within 30 days of the service being delivered, but the Act does not specify the amount of this payment.
The Act also supplements state surprise billing laws by creating a "floor" for consumer protections against surprise bills from out-of-network providers and higher cost-sharing responsibility for patients. It is important to note that the No Surprises Act does not replace state laws but rather sets a minimum standard for consumer protections. As long as a state's surprise billing law provides at least the same level of protection as the No Surprises Act, the state law will generally apply.
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Learn how to appeal a decision
If your health insurance claim has been denied, you can appeal the decision. The first step is to contact the insurance company and ask them to explain the reasons for the denial. This information will be useful when writing your appeal letter.
Before you begin the appeals process, it's important to understand the details of your health plan and the billing issue at hand. Familiarize yourself with your health plan policy benefits, including deductibles or copayments you may be responsible for. Knowing this information will help you determine if a bill has been incorrectly charged.
Next, you should write a professional letter to your insurance company. Address the person who denied your claim, state the reason for your letter, and provide a brief overview of your case. Include copies of supporting information, such as medical information, and leave anger out of the letter.
Keep a record of all communication with your health insurance company, including dates of calls, names of people you spoke with, and the information discussed. Be persistent—if your first appeal is denied, don't give up. You have the right to ask for an additional internal review and, if that is denied, you can request an external review by a third party.
Each insurance company has a specific appeals process, and you'll need to follow all the steps carefully. Make sure you find out what forms you need to submit, and how long you have to appeal the decision. You may need to submit your internal appeal within a certain timeframe, such as 180 days from when you received notice that your claim was denied.
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Frequently asked questions
A surprise medical bill is an unexpected bill, often for services received from a healthcare provider or facility that is out-of-network. Your health insurance may not cover the entire out-of-network cost, leaving you with the remaining bill.
If you received a surprise medical bill, you may be protected by the No Surprises Act, which protects you from certain out-of-network charges. You can also contact the No Surprises Help Desk to submit a complaint or dispute the bill.
First, make sure you actually owe the bill. If you are unsure, talk to the accounting or billing office of your provider. If you disagree with the charges, you have the right to an appeal with your health insurance company, both internally and externally. You can also dispute a medical bill with a debt collector or credit reporting company.
