Over the last few years, I've encountered several major issues with medical billing. It's made me quickly understand how to dispute your medical bill, get errors corrected, and reduce your payment.
First, I was incorrectly billed for the wrong procedure - one that cost almost 10x more than the one I had. Second, I had a procedure done at one location, and again at a second location, with the second location charging almost double the first.
The fact is, I don't "use" a lot of medicine. If these errors happen with this frequency - looking at my bill history, I put the error rate at roughly 2% - it's likely impacting others as well.
I wanted to put this ultimate guide for disputing a medical bill together so that you know exactly what to do if you think your medical bill is outrageously prices or plain wrong.
My Medical Billing Issues
As I mentioned before, I had both an incorrect billing issue and an "outrageous" pricing medical billing issue. I as able to resolve both successfully, and I learned a lot along the way.
Here's what happened to me:
The Broken Bone
In my first encounter with disputing a medical bill, I was charged for a surgery I never had! I had broken my ulna (wrist bone) and gone to urgent care. At urgent care, I got an x-ray, and they discovered it wasn't a bad fracture. As such, they put me in a wrist brace and sling, gave me some pain meds, and said I would be fine but let it heal for 6 weeks.
No cast, no surgery, nothing major.
But when the bill came, it was for $8,500! How could my urgent care visit and x-ray cost $8,500 was beyond me.
In the end, I discovered that the medical billing code was 1 digit off - meaning they billed me for a broken ulna surgical repair (actual surgery to repair the bone) versus a broken ulna non-surgical consultation. One error in medical billing send the price from about $800 for the urgent care visit and x-ray to $8,500.
The Expensive CT Scan
I've had two CT scans in my life - and for some reason, one was double the price of the other. The first CT scan was at one office, and it ended up costing $600. My doctor booked my second appointment at another office (due to scheduling), and the bill for this one came back at $1,200. For the same thing!
In this case, there was no billing error - just outrageous pricing. After a few phone calls and discussions, asking the right questions, and talking to the supervisor, I was able to get the bill reduced by 50% - to the same cost as the other procedure.
General Notes Before Disputing A Medical Bill
Before we dive in on the step-by-step way to dispute a medical bill, there are some general notes I want to cover first.
When disputing a bill, it's important that you do your research and understand what happened and what's going on. That way you can help troubleshoot the problem without passing blame. Customer service reps will be much happier to work with you if you adapt this approach.
Second, realize that mistakes will happen. Even if 99.999% of medical bills are done correctly, there will still be errors. People still process these. Be sympathetic up front to this.
Third, take diligent notes of all your conversations and encounters throughout the process. You should record conversations if possible (and allowed), and get things in writing. At a minimum, I recommend:
- Date and Time
- Who you spoke to (first and last name, ID number if possible)
- Details of the conversations
- Commitments from the company/individual with specific timelines to follow up (i.e. When can I expect this to be resolved? When should I follow up if I don't receive anything?)
- If on a cell phone, screenshot your phone at the end of the conversation to highlight the phone number you called, and the length of time you were on the call. If you can't do this, keep your phone statement with the call.
If you're mailing documents or doing any written correspondence, I recommend:
- Ensuring you keep a copy of everything you send, with date mailed
- Send all mail certified mail with return receipt - put the return receipt with your copies of what you sent so you have proof they received it
Finally, when disputing a bill, it's important that you ask about the due date of the bill. You want to ensure that collection on the bill is paused or suspended while the bill is being disputed. If they don't do that, ask that the due date be extended out a period of time.
The bottom line is you don't want this company to send you to collections while you're disputing their bill.
Step 1. Review Your Bill & Explanation Of Benefits
The first thing you get (typically before your medical bill even arrives) is your explanation of benefits from your insurance company. I would venture that 95% of people throw these away and don't even know what they are for.
Next, your actual bill will come in the mail.
It's so important that you review BOTH your medical bill AND explanation of benefits. This could be the first sign of something wrong.
First things first:
What Is An Explanation Of Benefits?
The Explanation of Benefits is a document provided by your insurance company the explains your insurance benefits as it pertains to a bill.
While every company lays out their Explanation of Benefits differently, you will usually see something like the following:
- Amount Billed By Provider (this is how much the doctor or hospital charges)
- Plan Discounts (this is a discount negotiated by your insurance company)
- Amount paid by insurance company
- Amount you will owe the provider
Most explanation of benefits forms will also include information about your deductible, co-pay, co-insurance, and more.
If a procedure is not covered, the explanation of benefits will also typically have a code or error, with a short explanation as to why it's not covered. To get more information, you typically have to call.
Here's an example:
How Does An Explanation Of Benefits Compare To Your Bill?
Now that you understand what the explanation of benefits it - you need to compare it to your bill. Your bill should exactly match the explanation of benefits. This could be your first sign of an error!
In some cases, I've seen medical bills that forget to apply the "plan discount" and so the patient is billed a higher amount than the Explanation of Benefits states. This is why it's essential that you compare the two.
However, some companies may combine multiple bills into one. For example, I received the following bill for $192.00:
However, at first, I only saw this Explanation of Benefits:
As you can see - my Explanation of Benefits was $24 short of what they billed me. However, upon closer inspection, they combined two Explanation of Benefits into one bill (this EOB and the EOB from above for $24). The company clearly billed my insurance company two separate times, but only billed me once.
However, if you receive your EOB and your bill, and you believe something is wrong, you need to get a more detailed picture.
Step 2. Get A Detailed Line-Item Bill
Once you've gone over your Explanation of Benefits and Medical Bill and you believe there is a problem, you need to request a detailed line-item bill. You can typically do this by calling the medical billing department listed on your statement, or in some cases, you can go online and print it.
What you're looking for is a detailed bill that lists out everything:
- Date and Time
- Medical Billing CPT Code
- Description
- Total Price
- Insurance Adjustment
- Patient Amount Due
Here's an example:
As you can see, when you have a procedure done, you can have a LOT of billing codes for the same event. If you have a hospital stay, the list could be huge.
But it's on this list that you'll be able to spot any errors in billing. The CPT Billing Code is key. To review your bill, you want to search for the billing code listed on your detailed bill.
For example, CPT Code 85025 is a blood test to check white blood cell count and more. There are multiple websites that allow you to search CPT codes, but I've found Google search to work best. Especially because it will find discussions around these codes for medical billing issues.
In my case, it's where I discovered I was billed for the wrong procedure. I was billed for Ulna Surgery, when I didn't have a surgery, but just an examination. There was a 1 digit error in the code which resulted in a 10x medical bill.
However, just finding the error is only the start of your medical billing dispute.
Step 3. Call The Medical Provider Billing Department
Once you've figured out what the issue is, it's time to start making some phone calls. The first stop is simply calling the medical billing department's customer service line and talking to them.
I know this sounds crazy, but you have to start here. So many people want to jump to lawsuits, when they haven't even started to address the problem with people who can potentially fix the issue.
Depending on the issue (either incorrect billing or a price dispute), you will want to take one of two approaches.
In the case of an error, simply tell the representative that you've found an error and would like to dispute it. Ask what the process entails.
Typically, the customer service agent will tell you:
- They will put in a request for their team to research the issue
- They will put your bill on hold while they research the issue
- They will give you some type of timeline to hear back on the request (typically 4-6 weeks)
Going back to the beginning of this article - make sure you document this in detail. Confirm with the agent what part of your bill is on hold - is it the total balance or just the disputed item. If it's just the disputed item, you need to make sure you pay the rest of your bill on time.
If you're simply calling to dispute a price or total amount of the bill, the customer service agent may be able to help you.
When I first called the billing department to dispute the price of the CT scan, I made it come across as this was a burden to pay double what I had previously paid. Without even skipping a beat, the agent on the phone said she could immediately reduce my bill by 20% if I made the full payment on the phone with her.
From doing my research on this article, this seems to be a fairly common practice with medical billing. In exchange for something immediately, most companies will offer a serious reduction in price.
However, just like every call center and customer service center, medical billing departments have supervisors too. And if you can speak to a supervisor and explain your story a bit, you might have better luck securing a bigger discount on your medical bill.
For my story, I was able to get them to match the price of the procedure, effectively giving me a 50% reduction on my medical bill.
Step 4. File An Appeal With Your Insurance Company
If you're covered and using your insurance to pay for a medical procedure (or at least part of it), a great way to make progress on disputing your medical bill is to also file an appeal with your insurance company.
This can really work in your favor if there is a medical billing error (like I had with the ulna surgery that never happened). You see, your insurance company doesn't want to ever pay more money than they have to. If you discover an error, even if they've already paid it, they might be incentivized to go back to the medical provider to resolve it as well.
That helped me a lot in my case. My insurance company still had to pay more money than they should have when it came to my broken wrist. They opened a dispute on their end, after I had opened a dispute on my end.
If you were incorrectly billed for a procedure and not only are you having to pay a lot of extra money, but your insurance company is too, they will want to know about it. And, it could help you get the entire situation resolved.
Step 5. File An Appeal With Your Medical Provider's Patient Advocate
Depending on your medical provider, they may have a patient advocate that could help you reduce your bill, help expedite resolution of errors, and more. Patient advocates are usually found in hospitals and large medical provider networks (like HMOs) that serve a lot of patients.
These people are exactly what they sound like - people who advocate on behalf of the patient. If you're not getting resolution (or things are taking longer than promised) with the billing customer service department, getting a patient advocate involved can be very helpful.
Patient advocates are also typically empowered to give discounts to bills as well. Even if it's not error related, they could help in times of hardship. They also have great connections to resources that can also help you if you can't afford your medical bills.
Step 6. Contact Your State Insurance Commissioner
The next step if you can't find a resolution to your medical billing dispute is to loop in your state regulators. Insurance is handled at the state level by a State Insurance Commissioner. While laws vary from state to state, most states have departments that are willing to help consumers in their states navigate the complexities of health insurance.
When you contact your state insurance commissioner for disputing a medical bill, it's essential that you have all of your paperwork and documentation in order.
You will typically need to fill out an official complaint form, and you can then attach your own documentation to support.
If there is a true medical billing error not being resolved, this is where you can clearly state the error, the CPT codes that were inaccurate, what the codes should have been, and the potential estimated difference in price.
If your claim is simply being denied by your health insurance, this is also the appropriate place to dispute that request. In some states (like California), there is a specific request for an Independent Medical Review to determine if you should be covered.
Step 7. Consider Legal Counsel
Finally, the last step, if you're still not getting resolution on your medical billing dispute is to seek legal counsel. You will want to find an attorney that specializes in medical billing disputes.
Most attorneys will do a free call to determine if they can even be of assistance to you and if you potentially have a case. They will also tell you what the costs might be. It could get expensive.
To find an attorney:
- Contact your state bar association for a referral (many state bar associations have referral services)
- Search for attorneys on a platform like Avvo, which has attorney profiles. Avvo also provides a record of client reviews and peer endorsements, which can be helpful in selecting an attorney.
- Once you find an attorney you might want to work with, cross-reference the attorney with your state bar association to see if that attorney has any record of public discipline.
- Do a Google Search of that attorney to see if their name comes up in a good way (for example, through press or publications) or in a bad way (such as being sued by a government agency or regulatory body for misconduct).
Final Thoughts
Disputing a medical bill and reducing your payment can be stressful and frustrating. Navigating a complex bureaucracy, having the threat of creditors coming after you if you don't pay, and simply the time it takes to get anything done make this one of the most unpleasant experiences a consumer can face.
I wanted to share a few reminders though.
First, don't worry about your doctor. In many cases, doctors don't get involved in billing at all. They don't know if you paid or didn't pay. And they aren't suffering from you not paying your bill. Realize that your doctor's number one priority is simply your health.
Second, don't worry about your credit report. These disputes take time (a lot of time). And in some cases, you might see your bill turned over to creditors or reported on your credit report. Luckily, the laws have been changing in consumers favor. Last year, new rules made it so that medical debt cannot be posted to a credit report until it's at least 180 days past due. And if it is paid and/or resolved, it must be removed from the report. You can read more here.
So, if you're disputing your medical bill, don't let your medical provider hold your credit report over your head.
If you've successfully disputed your medical bill, or lowered your payment, we'd love to hear about it. Leave a comment and share your story below for others to know about!
Gawayne Vaughan says
Great points! As a medical doctor, I can say I am always willing to change a code if it is wrong. I can also tell you that you can get different rates whether you choose an independent doctor or a large medical group. Choose independent if you are able to reduce your bill!
Robert Farrington says
How involved are you with the billing? I’m always curious to know.
Captain DIY says
This is a fantastic resource, thanks for putting this together! I haven’t had this happen to me yet (that I’ve noticed) but I’ll be keeping a closer eye on those EOBs!
Robert Farrington says
Glad you know what to double-check now!
Mike says
Thank you. This is indeed very helpful.
My situation is a bit unique, so I went for a treatment procedure and they gave me an estimated cost based on all the information I provided to them. They suggested it will cost me estimated $400. I said that’s fine let’s do it.
Later, I got a bill of $1200, when I inquired with the billing office, they were not helpful. Absolutely arrogant. I requested to speak with supervisor, no supervisor ever returned my call.
Then I decided to send out couple of emails to the care provider office, later I got a response.
At first they blamed on code, that my insurance company did not cover. Later when I questioned more they blamed totally on my insurance and deductible.
And now they are not buzzing. I am leaning to take legal route.
What else should I be watching for ?
My biggest frustration was the 3 times error in estimate. They kept saying it was just an estimate. But how come estimate can have error in the range of thousand for the exact treatment and insurance situation. They clearly did not pay attention when giving an estimate, and had I known it will me more than thousand dollar then I would have rejected the procedure.
Any help will be appreciated.
Robert Farrington says
Did you find out the code? Did you get a detailed breakdown of what you were billed? Have you sent a certified letter asking for this information with a reasonable timeline?
Mike says
The code was the same for both estimate and actual bill. Earlier they blamed on code not approved by insurance then when I asked more they stopped giving justification and said that was just an estimate. I called insurance and they said provider never called them until 2 days ago to get some clarification. I sent emails on the bill that was sent to me and I have their formal reply that I requested.
I wonder if they can be legally held accountable for giving me inaccurate estimate, that was 3 fold lower than actual bill they sent.
Mike says
Any more thoughts on my situation? You think I can dispute these charges legally ?
Robert Farrington says
I get that the code was the same, but was it correct for the procedure you had? Once again, did you actually send a certified letter disputing it, with copies of your estimate? Is there a reason they provided why the estimate was so different than the final bill?
I think you can still dispute it, but you have to dig in a bit and figure out why the discrepancy exists.
Stefani Tucker says
Hi! My sister had a medical procedure done 3 years ago. At that time, she had both a primary and secondary insurance so it was almost totally, if not totally, covered. 6 months ago, she got a bill from the doctor for $1,000. This was the first bill that she had received on this. She called the billing department and spoke with someone and they had sent the first bill 1 year ago but to the wrong address (still 2 years after the procedure). Apparently the secondary insurance didn’t pay what they should have BUT they blamed it on the billing department not providing them with what they needed. The lady she spoke with at billing told her that she would look into more and call her back. Well she never called her back and they send her bill to collections. This is the kicker, she no longer has that secondary insurance. She would have disputed this with the insurance however since it’s been so long and she is no longer covered under the insurance then they aren’t really working with her. What are the steps that she should take? Thanks!
Robert Farrington says
So, to clarify, she received a bill 3 years late, BUT:
1. Primary insurance covered everything they were supposed to
2. Secondary insurance didn’t cover the proper amount due to late billing
3. She still had an outstanding balance that was sent to collections
At the end of the day you still have the responsibility for any balance due. You can file a complaint withe the doctor’s billing department (or manager), or even attempt to let the doctor himself know if it’s a small practice. In some cases, that would resolve it.
Second, you can file a dispute with the secondary insurance that didn’t pay correctly. They may put pressure on the doctor’s office – as many contracts have billing timelines, and failure to bill on time also means they can’t bill the patient. You need to check.
Finally, if it’s a specific issue with the secondary insurance company, you can file a complaint with your state’s department of insurance.
But at the end of the day, she needs to pay what she actually owes (which may also include late fees at this point – but she might get those waived due to the dispute).
Anna says
Hi,
Thank you for the article, i hope to be able to dispute my bill using the tips you gave here.
My husband was bit by a squirrel in the park. As it could potentially carry rabies we went straight to the ER. This was TWO days before our insurance plan was active so we had to do a self-pay.
We came into ER, he had his BP checked and we were directed to the waiting hall. About two hours later we saw a doctor passing by, since we were waiting for so long and we had our little son with us, I asked the doctor if he was going to see us. He asked me for my husband’s name, looked it up, said “squirrels don’t carry rabies. The nurse is going to take care of you.” That’s it. TWO sentences. Never spoke with my husband as my husband doesn’t speak English.
The nurse came in, gave him a tetanus shot and left.
Several months later we wee billed by the hospital for ER and nurse services – $1575 orignally, reduced to $200.
BUT the doctor billed us separately for a service code that says “extensive trauma examination “. $1,175. I filed a dispute within their billing system right away, they reduced to $705, but THERE WAS NO EXAMINATION AT ALL. I’ve been writing emails, trying to call customer srvice, they direct me to emails again. A year later I get a phone call from collectors requesting payment.
I’m not sure what to do at this point as this doctor apparently belongs to a physicians group located in a different state, there’s nowhere to physically go to or talk to. All I get is automated emails and ame bill over and over again.
Not sure what my options are at this point…
Robert Farrington says
Chances are you’re not going to get out of the doctor bill – that’s how hospitals do it. You pay the hospital AND you pay for the physician. Also, chances are the doctor still reviewed your husband’s chart, spoke with nurses behind the scenes, and made the decision to allow him to be discharged.
What steps have you taken to dispute it? Did you get a copy of his medical records from the hospital to see what the doctor notated? If he didn’t notate anything on the chart, you might have a better case to dispute it.
kate says
Hi, is there a minimum debt amount for collections? Does it depend on the state? I live in Michigan and owe $20 to a medical provider; I don’t want to pay it based on substandard care and poor hygiene of the doctor during the visit. What are the ramifications of not paying?
Robert Farrington says
Nope, no minimum. I’ve seen amounts as low as $50 sent to collections. The big ramifications are they will add interest and fees to that amount, and the longer you avoid it, the bigger it grows. In a few years, it can be $1000s. Then, they can sue you, get a judgement against you, and garnish your wages, etc.
Don’t mess around over $20. If you were dissatisfied with the care, file complaints with the Department of Health in your area, and the state board.
Amber says
This is all very helpful info but who do I file a complaint with if my visit was self-pay, no insurance? I’ve already disputed the bill in writing and I’m not getting anywhere! The facility and doctors group are trying to bill my ER visit for an ear infection at a Level 3 and Level 4, respectively! This is clearly an attempt to inflate the bill for a non-emergent visit that consisted of looking at my ears and prescribing me oral antibiotics and steroids. The hospital is trying to charge me over $1000 and the doctors group $1400! I got a “discount” from the hospital paying $300 upfront. Thanks for any info
Robert Farrington says
Did you get your medical record and see what the diagnosis was? If the diagnosis was wrong and they are billing you for something you didn’t have, then you can start to file complaints with them if they don’t fix it. Consider writing the CEO of the hospital and the owner of the practice with the information and show where it’s wrong, steps you’ve taken to fix it, and how you are not getting results.
Susan E Stoltz says
My grand daughter was in for 2 tests recently at a Children’s hospital. She is a hard stick and with the first test the RN used J tips to administer an IV. She tried two times and had to call a surgical nurse who was successful in using the J tip. (3 J tips were used). The second test, done on another day was a repeat of the same scenario. The RN tried three (3) times before calling in the surgical nurse, who got it on the first try. Her mother commented more than once during these attempts, that her daughter is a hard stick. Can you get a surgical nurse? The RN just kept trying.
With that said, the bill reflected $700.00 of J Tips used. They are not covered and the insurance seems to think my daughter is responsible for all the tips. Both my daughter and I think that the two J tips that were successful should be the only ones that she should be responsible for. My daughter is a single mom and is working hard to make ends meet as we all are.
She has called both the insurance and hospital and neither of them will budge. They say she is responsible. My two questions I have is: 1. Does this case have merit? and 2. Shouldn’t the hospital staff be more aware of their role in the amount of product they use especially if the product is a one time use?
Robert Farrington says
1. Probably not. While it’s annoying, it happens, especially in a hospital setting.
2. Yes, they totally should and I think your daughter should still write a complaint to the hospital, explain they didn’t listen to her, as a result, you got this bill. It likely won’t change anything, but a well written letter to the hospital CEO can help. Also, posting on social media can help.
It’s more the point they didn’t listen to your daughter and the care needed, then wasted the money attempting something that wasn’t going to work.
Romi S. says
I and my wife visited Dr. Indu Menon at UT SouthWestern office in Irving, Texas for the first time for preventive EKG tests. Our primary doctor at work did the wellness check including blood work but did not have EKG facilities. Our Insurance covers preventive EKG at 100%.
Dr. Indu requested to see my blood reports from work, which I provided. I never asked her for any advice, and she conveniently coded the visit as Diagnostic EKG for Hypertension instead of Preventive EKG. So instead of being 100% covered by the insurance, the vendors emptied my Health Fund account and is sending me a bill for the remaining balance, a total of nearly $650 in bills. It looks like if they get the slightest chance, they will over-bill you.
Now is the funny part. For my wife’s visit, I guess the Dr. found a more innovative way. She coded my wife’s visit as EKG for Obesity. We both have never visited this doctor or their medical group before, and they decided to code whatever to charge more and now the billing department at UT Southwestern is not budging. The discussion with insurance and billing office sounds like the doctor is the only one who can correct the billing coding. But UT Southwestern wants me to pay for another doctor visit if I want to discuss the old bill with the doctor. Just feel cheated by these crooks.
What do you recommend? Is this a valid discussion to pursue?
Robert Farrington says
Yes, it’s definitely a valid discussion to pursue. Follow the steps listed. Also make sure that your primary doctor didn’t refer you for something specific. Follow the steps listed in the article.
Lee says
I was having some pain in my wrist for several days and decided to run to a close emergency clinic on my lunch hour. Doctor took a look said he didn’t think was fractured but would X-ray it. After 15 minutes he said not broken or fractured to my relief. He then gave me a Velcro cuff and said take it easy for a few days. I just received my claim notice from my insurance. They billed over 11000.00$! Yes thousands! My portion just under 5000.00! I am waiting on a bill at this point I will definitely use your advice this seems extremely exorbitant ! Healthcare blue book is no where near this! Just The Velcro cuff was billed at over $2000.00. Is there no cap or guidance on what clinics can charge?
Robert Farrington says
There’s no cap or guidance, but you need to see what the codes were that you were billed for. If nothing was done, I wouldn’t expect it to be that high.
Lee says
After some more investigation ,this “urgent care “ facility is stating they are a stand alone ER., as such can charge hospital ER fees . We have many small urgent care facilities in town ,I was unsuspecting that this was any different. My insurance company is working with me , I am also filing a provider complaint with the state. To walk in the door was over $5000. I have the codes they filed claim on my EOB, Legislation passed approval for stand alone ERs in 2009 I don’t believe i will be able to reduce my bill. They are legally within their rights to charge exorbitant fees, and I found many stories of unsuspecting consumers receiving sticker shock believing they are visiting an urgent care facility. What recourse is available?
Robert Farrington says
Beyond continuing to dispute it, you might involve local media – especially if you have a “consumer reports” type guy on the news.
Rachel White says
On May 1st I began a new medication for nausea, on May 28th I began having seizures & we went to the facility the paramedics suggested, one we’d never been to. Long story short, the facility treated us horribly, left me on a bed pan for over 15 minutes, told me I was faking it, did nothing more than hook me up to an EKG, discussed me loudly out in the hallway as a drug seeker (I never asked for any), & one of the nurses accused my husband of laying a hand on her when we left due to their attitude, calling a security guard on us. We went on to another ER by car, who took wonderful care of me. Turns out I have non-epileptic seizures. I filed a complaint with my government insurance (I’m disabled) & mailed them a letter detailing all that happened, & posted some of it on social media. How can I challenge the bill & pursue legal action? I’ve not found a clear answer & I’m still getting bills. My insurance said that if they choose to deny the hospital payment, the hospital will likely just send me a bill for the whole payment, which is infuriating since the EKG was the only thing they actually did.
Robert Farrington says
What else did they bill you for that the technically did not do? Poor service isn’t no service.
Manik K says
I have been fighting with a medical equipment provider, it started with provider issued equipment on a rental basis which was lacking a pre-authorization from my insurance and insurance started denying the claims, where as provider some how started billing me directly when ask they say I did not have medical coverage so now they billed me for entire equipment as sale. total amount is around $1200, finally it went to collection and ended up on my credit reporting.
I have worked hard to keep my credit history cleaned and just this instance damaged my credit report.
Do I have a case here to fight further to take out the collection from my credit report?
Robert Farrington says
You can work with your insurance company if it was covered but they denied it. It’s not the provider’s job to validate your insurance, it’s your job. Depending on timing though, it could be a hard fight.
If you didn’t pay the bill, then the company can report it to collections.
Manik K says
Thank you, I was wondering is not that provider’s mistake not taking the pre-authorization and started the service.
I tried calling insurance and provider multiple time looks like insurance was covered but due to the lack of pre-authorization they denied and on 2nd month I received the bill for sale of equipment.
Robert Farrington says
No, that’s not the providers responsibility as much as you’d like it to be.
Manik K says
Ok got it, thanks.
Amy says
Long story short, had my doctor refer me to the local hospital for a couple of tests back in February. Before the day of the tests (which were outpatient) I was called by the facility and told they had already checked with my insurance and they knew what my patient responsibility would be, and if I paid in advance I would get a 20% discount. Seemed like a no-brainer, so I did the early payment. Had the two tests done. A couple of weeks later I get my EOB and find out they hospital had over-estimated by patient responsibility and that I was owed a refund. It took them about 30 days, but finally in early April I was refunded by $45. So, I consider this case closed. 5 months later (after the Feb testing), I get another EOB in the mail for the same two tests, however my patient responsibility (because I haven’t meet my annual deductible) has gone up by $200. I contact my insurance (who isn’t super helpful, since this isn’t their money), but they do admit it looks like “the hospital unbundled the bill” and they agree to a claim review. The hospital has sent me 3 bills in 5 weeks and is already threatening collections, and my insurance company hasn’t even issued a finding on the review. Is either of these things legal or correct. Should the bill have ever been changed and should they be threatening collections already? Is there ANY protection for the patient?
Robert Farrington says
You should get a copy of your receipt, and payment made originally, and send that to the hospital saying this has already been paid. Then, follow the steps in the article above. Sounds like you haven’t really gotten past step 1.
Amy says
I actually have done step 1. I have both EOB’s (the original and the “updated”) and reviewed them both. I only have the “current” bill, as I was never sent a paper bill for the initial amount since I prepaid. All I have is a receipt of payment and then of the refund. The insurance company accepted an updated claim in late July and processed it, leading to the additional bill. When the claim was first filed in February, it had 2 line items, one for each test (a mammogram and ultrasound). When the claim was refiled, the hospital broken the original line 2 (ultrasound) into lines 2 and 3, treating a single ultrasound as two (one for each breast), which doubled the amount due for the ultrasound. My question is, what legal right do I have, if any to fight this “updated” bill? Can a medical facility, 5 months later, change a bill in this manner and come back after a patient for more money?
Thomas Miller says
I’ll try what you suggested, but I’m not hopeful. My doctor had me undergo an electrocardiogram stress test a couple of months ago, and when I showed up I was only then informed that the insurance company had denied covering it. The hospital told me that if I paid for it myself, it would cost about $500 plus another $100 for interpretation. Given my income, that’s A LOT of money for me, but since my doctor was trying to determine if I was suffering from Congestive Heart Failure I decided I could just about manage it. When I finally get the bill it’s for $1600! The insurance company deigned to pay for $600, but I’m now stuck with a $1000 debt and don’t know how I’m going to pay for it. Unless it’s reduced I’m going to have to cancel my ACA insurance and use my part of the premium payment to pay off the bill. If they’d given me an accurate cost estimate, I’d have never gone ahead with the test.
Dad says
Corrective surgery of a birth defect of my infant son. Surgeon and surgery covered by insurance but anesthesiologist was not. I had no choice in provider of the anesthesia, that was the surgeons call. Since I had no choice, shouldn’t insurance cover it? Sent the bill to arbitration through the department of insurance, was not part of the phone call between provider and insurance, got an eob that says they settled but we still owe $4200. How do I take this further? I feel like I’m on several steps at once but mostly on step 7? Would it do any good to call and make an argument with insurance? Thanks for the help.
Robert Farrington says
What state are you in? In California, that’s illegal due to state laws passed in 2007. I believe New York is the same.
Otherwise, sadly, because it was elective, if your state didn’t pass a law forbidding it, it’s legal… not right, but legal.
Dad says
I am in Texas. Of course I do not consider hypospadias repair to be elective but I guess the medical community does? The real trouble comes at part two of the repair, same surgeon, same anesthesiologist, so anticipate same result or worse. Thanks you for the advice I appreciate your time.
Jake says
I’m in your same boat. In Texas. Just got a bill for $4200 for anesthesiologist from my wife’s childbirth. She had an epidural. I guess the 10 minutes the anesthesiologist was in the room is going to cost us $4200. Apparently, since we have an HMO, we are not eligible for arbitration in Texas. I assume you have a PPO?
Rachel says
Hey! I had a mucocele removed about 6 months ago and recently received a bill from the surgery center for 1300 dollars. On this bill it says it was changed from my insurance provider to ‘self pay’. I have no idea why. I plan on making the calls today, but does anybody know why this would have happened?? And who would have made that switch for me? I’m hoping this is a simple mistake and I don’t really owe that. Fingers crossed!