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
- 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).
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!
Robert Farrington is America’s Millennial Money Expert® and America’s Student Loan Debt Expert™, and the founder of The College Investor, a personal finance site dedicated to helping millennials escape student loan debt to start investing and building wealth for the future. You can learn more about him on the About Page or on his personal site RobertFarrington.com.
He regularly writes about investing, student loan debt, and general personal finance topics geared toward anyone wanting to earn more, get out of debt, and start building wealth for the future.