Navigating Surprise Medical Bills: Understanding Your Rights And Options When Faced With Excess Charges

It can be stressful to receive a doctor's bill for more than your insurance covers. The cost of medical care is notoriously steep, and it can be confusing to understand what your insurance covers and what you must pay for yourself. However, there are steps you can take to address the situation. Firstly, it is important to understand your insurance plan, which is a cost-sharing agreement between you and your insurance company. Many insurance companies cover preventive care and require you to cover all other costs until you reach a specified deductible amount. Once you reach this amount, the insurance company starts paying for covered services. After receiving care, the medical provider will send a bill to your insurance company, which will then send an Explanation of Benefits (EOB) to you and the provider, outlining what they will pay for and what you are responsible for. If you receive a bill for more than you expected, you can ask for an itemized bill to check for errors and compare it with the EOB. You can then negotiate with the billing department and your insurance company to resolve any discrepancies. If you are unable to resolve the issue, you may need to consider switching to a different doctor or insurance plan.

Ask for an itemized bill to check for errors

If you think you're being overcharged for medical services, it's important to ask for an itemized bill. This is a detailed statement provided by your healthcare provider or medical facility that lists all the individual services, procedures, and supplies used during your treatment. It breaks down the costs for each item, allowing you to identify and dispute any errors or discrepancies.

Contact the Billing Department

Call the healthcare provider's office or the billing department directly. You can usually find their contact information on their website, your billing statement, or your medical records.

Provide Your Information

Be prepared to provide your full name, date of birth, contact information, and patient identification number if applicable. This helps the billing department locate your records and verify your identity.

Make the Request

Politely ask the billing department representative for an itemized bill, specifying that you want a detailed breakdown of all the services, procedures, and supplies used during your treatment, along with the associated costs.

Specify the Format

If you have a preference for receiving the itemized bill (e.g., email, mail, or fax), mention your preferred format during the call. Provide your correct contact information, such as email address, mailing address, or fax number.

Follow Up if Necessary

If you don't receive the itemized bill within a reasonable timeframe (usually 1-2 weeks), follow up with the billing department to check on the status of your request. Remember to remain polite and patient throughout the process.

Once you receive the itemized bill, carefully review it for any errors or discrepancies. Compare the charges with the hospital's listed prices and use tools like the Healthcare Blue Book or FAIR Health to see the cost of similar services and procedures at other hospitals in your area. If you find errors or have concerns, contact the billing department to discuss and resolve the issues.

Contact your insurance company with any questions

If you have questions about your insurance company's coverage or the amount you have to pay, contact them directly. It's important to understand your insurance plan, which is a cost-sharing agreement between you and your insurance company. Many insurance companies cover the costs for preventive care, such as check-ups and vaccinations, throughout the year. For other services, you may be required to pay all costs until you reach a specified amount, known as a deductible. Once you reach this deductible, the insurance company starts paying for covered services.

After receiving care, the healthcare provider will send a bill to your insurance company, which will then determine how much they will pay for the service or visit and how much you are responsible for. This breakdown is shown on the Explanation of Benefits (EOB) provided by the insurance company. The EOB is not a bill, but it's important to review it carefully to understand what your insurance company is paying for, what it's not paying for, and why. If you have questions about what and how much was covered by your insurance company, don't hesitate to contact them.

In addition to understanding your insurance coverage, it's crucial to know the network coverage of your plan. If your doctor doesn't accept your insurance, you can try to get out-of-network coverage or find an in-network provider instead. Contact your insurance company and explain the situation; they may be willing to negotiate with your doctor. However, if the issue is that the doctor doesn't want to accept funds from an insurance company, you'll have no choice but to pay cash or find a different doctor.

It's also important to be aware of state and federal laws that protect patients from surprise medical bills. For example, if you receive care in an in-network hospital or for labs and imaging ordered by an in-network doctor, you are protected from surprise bills under certain laws. If you receive a surprise bill, there are resources available to help you resolve the issue.

Ask your doctor about the cost of the service

Asking your doctor about the cost of the service is an important step in understanding your medical bills. Here are some tips and suggestions on how to approach this conversation:

• Be proactive and don't hesitate to ask about costs: It's your right to know the cost of your medical care upfront. Ask direct questions such as "How much will this cost?" or "What is the cost of the treatment?". If you don't get a clear answer, don't be afraid to ask to speak to someone who can provide more detailed information.
• Understand your insurance coverage: Know what your insurance plan covers and what you are responsible for paying. Ask your doctor or insurance provider if you're unsure. Many insurance companies provide an Explanation of Benefits (EOB) document, which outlines what costs they will cover.
• Discuss alternative treatments: If the cost of a particular treatment is too high, ask your doctor about alternative options. They may be able to suggest less expensive treatments or medications, including generic versions or different dosages.
• Inquire about payment plans or financial assistance: If the cost is still beyond your means, ask your doctor about flexible repayment terms or payment plans. Many healthcare providers offer financial assistance programs or charity care policies for patients who qualify.
• Compare costs with other providers: If you're facing high costs, it's worth researching prices at other hospitals or clinics. You may find more affordable options, especially for imaging services or non-emergency procedures.
• Ask about the necessity of tests and procedures: Sometimes, doctors may order a series of tests or procedures that contribute to high medical bills. Ask your doctor about the necessity of each test, how it will help diagnose or treat your condition, and if there are any potential risks or side effects.
• Be informed about your health: Stay involved in your healthcare decisions and ask questions. Understanding your condition, treatment options, and potential side effects will empower you to make informed choices and potentially reduce unnecessary costs.

Compare the bill with the Explanation of Benefits (EOB)

Comparing the bill with the Explanation of Benefits (EOB) is crucial to ensure you're not being overcharged and to understand your financial responsibility. The EOB is a statement from your insurance company detailing the charges for the services you received. It includes information such as the date of service, the type of service, the provider's charges, and how your insurance company processed those charges.

• Check the dates and description of services: Ensure that the dates of service and the description of services on both the EOB and the bill match. This helps verify that the services listed on the bill were actually provided to you.
• Verify the provider's charges: Compare the charges listed on the bill with the "Provider Charges" or "Billed Charges" section of the EOB. This will help you understand the amount your doctor or hospital charged for each service.
• Understand insurance coverage and payment: The EOB will show you what your insurance plan covers and how much they will pay. Look for sections like "Allowed Charges," "Paid by Insurer," or "Amount the Health Plan Paid" to see the amount your insurance company has agreed to pay or has already paid.
• Determine the amount you owe: The EOB will also indicate the amount you are responsible for paying, often listed as "Patient Balance" or "Patient Responsibility." Compare this amount with the total charges on the bill. If they don't match, there may be an error or additional charges.
• Look for adjustments and reason codes: If there are any adjustments or reason codes on the EOB, pay attention to them. These codes explain why a claim was denied or adjusted, such as services being out of network or requiring prior authorization.
• Contact the provider or insurance company: If you notice any discrepancies or have questions, don't hesitate to reach out to your doctor's office or your insurance company. They can provide clarification and help resolve any issues.

Remember, the EOB is not a bill, and you should not pay anything based on it alone. It is a tool to help you understand your insurance coverage and expected costs. The actual bill from your doctor's office will include the final amount you need to pay, taking into account any payments made by your insurance company.

Request a reduced fee or flexible repayment terms

Requesting a reduced fee or flexible repayment terms is a viable option when a doctor bills for more than your insurance covers. Here are some steps you can take to achieve this:

Start Early

It is advisable to start negotiating as early as possible. Contact the billing department, your healthcare provider's billing agency, and your insurance company as soon as you receive the bill or Explanation of Benefits (EOB). Hospital bills are not usually sent to collection agencies immediately, so you have some time to negotiate.

Check for Errors

Review your bill for any errors or discrepancies. Billing disputes due to errors are common, and it is estimated that up to 80% of medical bills contain errors. Look out for duplicate charges, charges for services you didn't receive, incorrect diagnosis codes, or "unbundled" procedures, which are charged individually instead of under a single code. Ask for an itemized bill from your healthcare provider if necessary, as this will make it easier to understand the charges and identify any mistakes.

Ask for a Reduced Fee

Once you've addressed any errors, reach out to the billing office and ask for a reduced fee. Nonprofit hospitals are legally required to offer financial assistance programs, and many for-profit hospitals also have similar programs. Ask if you qualify for charity care or financial assistance. Have a recent tax return or income information ready, as the billing office may decide on a reduced fee based on your income level. Even if your income is too high for charity care, you can still request a reduction if you can demonstrate financial hardship.

Research the Insured Rate

If you are uninsured, research the "insured rate" for the services you received. Insurance companies often negotiate lower prices with healthcare providers. You can use tools like FAIR Health Consumer to estimate the cost of a medical procedure in your area. Contact the billing agency and ask them to honor the insured rate.

Offer to Pay Upfront

Some hospitals may be willing to offer a discount if you agree to pay the discounted amount immediately. This option may not be feasible for everyone, depending on their financial situation.

Negotiate a Payment Plan

If you are unable to negotiate a lower price, you can still ask for a more affordable payment plan. Hospitals and clinics usually offer interest-free payments, which is more advantageous than paying with a credit card and incurring additional interest charges. Negotiate with the billing office to arrive at a monthly payment that fits your budget.

Frequently asked questions