As if dealing with an illness or injury isn’t stressful enough, handling medical bills and insurance paperwork can add an additional layer of stress to your life. Maybe the doctor’s office or hospital sent you a bill with a mistake. Or maybe your insurance company unexpectedly denied your claim. No matter your situation, it’s important to stay on top of your bills or you may find yourself at the mercy of a bill collector. Fortunately, if you cannot handle all of this yourself, there are professionals who can help you. Our tips for handling medical bills will hopefully make your life a little easier!
It’s all in the details.
There is so much room for errors when it comes to medical bills. A code can be entered incorrectly. You can be confused with another patient. It’s entirely possible to get bills for services you never received. Therefore, it’s important to read over your medical bills with attention to detail.
The same attention to detail applies to your explanation of benefits from your insurer. Perhaps they rejected a service that is normally covered due to a clerical error or a change in policy. But you won’t know unless you read these statements carefully and compare them to the appropriate medical bills.
Yes, it’s all boring. And sometimes frustrating. But it’s necessary if you don’t want to overpay.
Before you make an appointment…
It’s best to avoid unexpected bills by taking the following steps before you schedule an appointment.
For starters, check in with your insurance company to:
- Learn if the services you expect/need are covered.
- Find out if you have met your deductible.
Additionally, call your doctor and/or hospital to confirm they accept your insurance plan, to learn if you need pre-authorization, and to ask about co-pays.
Importantly, ask for a “good faith estimate” for all expected costs, including a detailed breakdown of prices. Since the enactment of the January 2022 No Surprises Act, all medical providers must provide a good faith estimate when uninsured or self-pay patients request an estimate, discuss costs, or schedule a procedure.
If you schedule a procedure or appointment at least 10 days beforehand, the provider must give you a good faith estimate within 3 days of your request. However, if you schedule a procedure closer to the date of a procedure (at least 3 days in advance), the provider must provide an estimate the day after scheduling.
Unfortunately, there are currently no clear requirements regarding procedures for which you have less than 3 days’ notice. However, it can’t hurt to ask the doctor or hospital!
You can use these good faith estimates to compare prices across providers.
Most importantly, the law states that the final bill may not exceed the estimate by more than $400 per provider.
Before you pay a bill…
Don’t pay a bill until you are certain it is correct AND that the total due matches the amount stated on your insurer’s explanation of benefits (EOB).
First thing you should do is ask for an itemized bill if you didn’t receive one. Importantly, the law requires providers to give patients itemized bills when requested.
What if the bill doesn’t match your insurer’s EOB?
If your bill doesn’t match the numbers on your insurance company paperwork, call your insurance company. They will likely offer advice on next steps. If you have no success with your insurance company, call the doctor or hospital and explain the discrepancy.
Is your bill for the correct services?
Firstly, make sure the bill doesn’t contain errors, including duplicate charges.
Importantly, check if the billing codes match the care you received. To see what each billing code stands for, search online by typing in the code numbers and the text “medical billing code”.
Does the bill seem too high?
If you get a bill that seems higher than you expected, carefully look over the itemized bill. You can compare the amount of money charged for a particular billing code with what insurance companies say is a reasonable fee for your geographic area. You can find estimates for both in-network and out-of-network fees for health services on Fair Health Consumer’s website or on Healthcare Bluebook’s website.
What to do if you identify billing issues.
Although you can get refunds for overpayments from hospitals and doctors office, it’s a hassle you should avoid when possible. Therefore, try to resolve any issues before you pay a bill. However, don’t wait too long! If you don’t pay a bill within a reasonable timeframe, the doctor or hospital can send your bill to a bill collector, which comes with its own problems.
Steps to take.
If your bill contains a fee for services you didn’t receive, contact your doctor or hospital and contest the charges. Be polite, but persistent.
Similarly, if you learn all or part of your bill is much higher than the average price for your area, you can contest the charges as being unfair. Be sure to reference your findings from either Fair Health or Healthcare Bluebook. Additionally, you can ask for a “settlement amount” – an amount they will accept if you pay the bill that day. Medical billing experts say you may get a 30-50% discount with this tactic. Again, be polite and persistent.
You can also call your insurer with billing questions or concerns.
Importantly, when calling your doctor, hospital, or insurer, do yourself a big favor and keep track of all phone conversations. I suggest you write down the name of the person you speak with, the details discussed, and the next suggested steps.
Getting frustrated by a lack of closure?
If all else fails, you can take the provider to small-claims court.
Additionally, you can hire a medical bill advocate who can help you resolve your issues. However, realize this is not a free service, so balance how much the advocate will charge against how much money you stand to gain. See below for more information on billing advocates.
Has the insurance company denied your claim?
If your insurance company denies a claim, don’t give up too quickly. In some cases, your insurer may not have received all the needed information to accept a claim.
However, it’s also possible that your insurer denied your claim without a proper evaluation of your case. According to the laws in many states, to avoid unfair denials, doctors who work for health insurers must review patient records before rejecting claims for medical reasons.
Alarmingly, a 2023 ProPublica investigation found that for some cases, Cigna uses a computerized system to identify which claims to approve or deny by checking a list of tests and treatments approved for particular health conditions. A list of denials is sent to a Cigna medical director who quickly denies dozens of claims with a single click, without any review of information.
How often is this happening? The investigation found that during 2 months in 2022, Cigna doctors denied 300,000+ claims using this method, spending an average of 1.2 seconds on each case.
Insurers know that some patients will appeal their denials. .However, they also know many patients would rather pay bill than deal with the hassle of an appeal.
Importantly, the ProPublica report states that many other insurers use similar programs to evaluate claims.
What can you do if your insurer denies a claim?
Send a written letter describing why you think your policy should cover the service in question. And make sure you include a detailed letter from your doctor describing why you needed the service. If necessary, ask someone from your doctor’s office to call your insurance company for you.
If your can’t make progress with your claim, consider getting an external review by an independent reviewer – called an Independent Medical Review (IMR). Health plan enrollees have the right to ask for an IMR when coverage for medical treatments or services is delayed or denied by their insurer.
What about “surprise bills”?
“Surprise bills” occur when patients receive unexpectedly high bills from out-of-network providers when they receive care in an in-network facility. How does this happen?
Unfortunately, you can receive care from a doctor who doesn’t not have a contract with your insurer, even when your care takes place at an in-network facility. These surprise bills are more common with bills from anesthesia, pathology, emergency rooms, internal medicine, and ambulance services.
According to a recent study, out-of-network bills are increasing among inpatient admissions and emergency department visits to in-network hospitals. In fact, studies show that about 20% of emergency room visits have resulted in surprise bills.
Good news for handling surprise medical bills!
Fortunately, there is some very good news. As of January 2022, the new No Surprises Act bans surprise medical bills by instituting a cap on the pay doctors, hospitals, and air ambulances can collect for out-of-network care. Simply put, if you receive care at an in-network hospital, they cannot bill you more than a negotiated, in-network rate for any out-of-network services you receive while there. Instead, the insurance company and the healthcare provider must work out how the bill gets paid.
Importantly, if you don’t know about this new law, you might end up paying more than you should. Unfortunately, it might be up to you to make sure your hospital or other healthcare provider follows the law.
The law does not apply to all providers.
Importantly, the law protects us when we receive care in a hospital, but it doesn’t apply to many other places we receive care, including doctors’ offices, labs, birthing centers, or most urgent care clinics. Additionally, air ambulances, which often come with huge out-of-network bills, are covered by the law, but ground ambulances are not.
Watch out for “Surprise Billing Protection Forms”.
According to a Kaiser Health News article, out-of-network providers may present you with a form addressing their protections from unexpected bills, labeled “Surprise Billing Protection Form.”
This is critically important to understand – if you sign this form, it waives any protections and instead acts as a consent to treat you at out-of-network rates. These forms protect the provider, not the patients.
Furthermore, providers can catch you off-guard by giving you an iPad to sign without showing you what you are signing. Instead of blindly signing, insist on seeing the form before you sign!
If your provider asks you to sign this form, make sure it includes a “good faith estimate” of what they will charge you for your care. For nonemergency care, the form should include the names of in-network providers you could see instead.
Additionally, the form should explain that the provider can refuse to treat you if you refuse to sign the waiver.
Importantly, it is against the law for some (but not all) providers to even give you this form at all. This includes emergency room doctors, anesthesiologists, radiologists, assistant surgeons, and hospitalists.
If possible, don’t sign a surprise billing protection form if you notice a problem.
What if you have no choice about where to receive care?
You might have to sign the form if you urgently need care. In that case, consider these important suggestions from Kaiser Health News:
- Write on the form that you are “signing under duress” and note the problem (e.g., “Emergency medicine facilities are not allowed to present this form”).
- Take a picture of the form with your notes on it. Also, consider shooting a video of yourself with the form, describing how it violates federal law.
- Report it! There is a federal hotline run by the Centers for Medicare & Medicaid Services. You can call (1-800-985-3059) or visit the website to reporting violations of the new law barring surprise bills. Both the hotline and website help patients figure out what to do, as well as collect complaints.
What if you get a bill you think violates the No Surprises Act?
If you get a bill that you think violates the new law, there are steps you can take. For starters, you can call the Medicare hotline (1-800-985-3059) or visit their website to ask questions and/or file complaints. Additionally, many states have a Consumer Assistance Program (CAP) you can contact for medical bill disputes and health insurance-related questions. To see if your state has a CAP program, visit this page.
Additionally, you can try to dispute the bill with the hospital yourself. Contact the hospital’s billing department in writing, stating you believe the bill violates the No Surprises Act.
Help with medical bills for low-income patients.
Certainly, if you don’t have insurance, a medical bill can devastate your finances.
Did you know that in order to keep nonprofit status, the government requires nonprofit hospitals to have Charity Care programs that can cover some or all of your hospital bill if you qualify? Additionally, for-profit hospitals have programs for low-income patients as well.
If you or your loved one cannot afford your hospital bill, you can find information on your hospital’s charity care program by searching online with the hospital name and the phrase “patient financial assistance”. You can also call the hospital and ask to speak with someone in the billing department.
To take advantage of these programs, you must complete a potentially difficult and confusing application process. Additionally, you may have to persist to get an application since some hospitals deter applicants.
However, it can be worth your time and efforts, even if you already paid a bill – you might get a refund.
What are the requirements of charity programs?
Each hospital can decide the qualifying criteria. For example, a generous hospital may give free care to people earning less than twice the federal poverty level, and may provide discounts for people earning up to double the federal poverty level. But other hospitals may have less generous cut-offs.
Additionally, hospitals’ charity care programs can include exceptions, such as not covering bills for doctors who are not on their payrolls.
Not all medical providers offer charity care programs.
Importantly, the law only applies to nonprofit hospitals, although many for-profit hospitals also have programs. And only about 56% of community hospitals have nonprofit status – the rest are for-profit. Additionally, realize that doctors and other medical providers are not hospitals and therefore don’t fall under this rule.
You have to ask for help!
Unfortunately, hospitals often bill low-income patients, even when they have charity care programs in place. Disturbingly, a 2019 Kaiser Health News analysis of reports submitted to the IRS found that 45% of nonprofit hospital organizations routinely send medical bills to patients whose incomes are low enough to qualify for charity care. This accounts billions of dollars of medical bills sent to patients who likely would have qualified for hospital charity care programs.
Therefore, if you think you might qualify for a charity care program, it’s worth your time to look into your hospital’s financial assistance program.
What if you cannot get help through a charity program?
If you don’t qualify for a charity program, or you are not accepted, you can ask for a payment plan. Having a bill divided into smaller monthly payments can be a huge help.
Handling medical bills yourself?
If you are handling medical bills and insurance yourself, take the time to set up an organizational system. It’s critical to stay organized! Never pay a bill without examining it, making sure it seems accurate. And keep records of the bills you pay and the associated insurance statements of coverage.
Need professional help with inaccurate bills or denied coverage?
If handling medical bills is too overwhelming, or you’re struggling with a claim or bill that you think is wrong, you may want to hire a medical-billing advocate (for a fee). However, not all advocates are equal, so do your homework before you hire someone.
Firstly, ask your friends and family if they know of a reputable advocate. If no one has a lead for you, try Medical Billing Advocates of America, a professional organization for those who help with billing and insurance issues. You can use their website to find a professional in your area.
Before hiring help, be sure to speak with past/present customers; and get a written contract detailing the billing rate, services provided, and if they require payment if they cannot reduce or eliminate the medical bill in question.
More tips for handling medical bills.
Read these blog posts to learn more about handling medical bills and other money related matters:
- How to Save Money on Prescription Medications.
- Can You Comparison Shop for Healthcare Prices? Yes, and You Should!
- How to Shop Around for Healthcare Pricing.
- Reduce Your Healthcare Expenses.
- The Impact of the High Cost of Healthcare
NOTE: I updated this post on 4-3-23.