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.
Erica Stauver says
I’m curious to know what happened. I was given an estimated cost of $3,000 for a procedure. So I decided to go ahead and pay that and proceed. After the procedure they sent me another bill for $6,000. I feel as though this is so wrong. And I can’t afford the extra $6,000.
Gary Crawford says
Hi Mike, exact same thing happened to me also. Same amounts also! So, what did you end up doing?
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.
jenny says
Can you get the bill reduced for poor service? I mean you can do it everywhere else!
My son was at a clinic run by the corporation that owns his primary care’s office. My son was having difficulty breathing after 10 days of a bad URI (obviously viral at the start) – along with an intermittent fever. The PA gave him a breathing treatment because she could hear the wheezing and then released him with an inhaler. All through the night he did not improve. I took him to the primary 8 am the next morning. The doctor said he was very sick and needed prednisone and antibiotics added to his regimen. With a 10K deductible, a cold that turns into infection should not need 2 visits. She should have given him the antibiotic on the first visit because he had waited the requisite 10 days and things started getting worse – I don’t run to the doctor for every little sniffle. Additionally, she could hear the lung congestion and knew about the fever. The bills are 400 total and I feel that the first visit should be discounted.
Robert Farrington says
You can always ask (just like you would at a store), but just like at a store, there is no obligation for them to.
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.
HS says
I am in a situation where the insurance co denied a trial / research device. I was billed by the hospital over $3k for the device. The insurance co, in conference call with the hospital, indicated that the hospital is required to contact them prior to the procedure or use of a trial / research device and if they fail to do this, the insurance co will not honor the bill for the device and furthermore the contract states the hospital cannot bill the insured individual under this clause.
The hospital wrote off all but, what they claim is my co-pay portion. I am contending any % of zero is zero.
I have an email from 4 months ago stating they will get back with me regarding this. If a letter from collections is getting back with me, they did.
Any options here ?
Robert Farrington says
It depends on what it worth to you. Pay it and be done. Dispute it?
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!
Andy says
I was referred by my local doctor to have a check on my eyes. And it was an eye institute so my doctor said it would be free since the students helping the patients. So I went there and it was just some seasonal allergy. Before I left, I knew that I should check with the checkout about the bill I should pay. They did not say they were out of network and they confirmed that I had to pay nothing. Then they asked me for a followup appointment. After three weeks, I received the bill which is $200 and I realized that I should not trust them. Then I checked my insurance claims, I found two other $100 about the follow-ups. My point is they never told me about the out-of-network thing and the amount, and if they told me about the $100 per visit, I would not keep go there. By the way, the 2 follow-up visits were just very routine checks and I do not believe that would cost $100 per visit. What should I do first? Call the billing department first or my insurance?
Robert Farrington says
I would call the billing department of the eye institute. You might get somewhere if you tell them they confirmed you were in-network prior to going and were told it would be $0.
Ryann Kneehsaw says
Hi! Thanks for your tips on disputing a medical bill. I have a similar situation to your CT scan costing double the amount at a different location.
My two and a half year old daughter had heart surgery two years ago. In the space of three years we’ve had numerous echocardiograms done. In the beginning we went to one location but the last two years have switched to a different location for proximity sake. We use the same cardiologist and the most these visits have cost in the last two years has been $1700. We had a visit in March and the cost was $1200. On her most recent visit in July we were told we had to go to the other location because our doctor would no longer be available at the one we had been using. Same procedure we’ve had done a dozen times but the bill is over $5000. With our current insurance this procedure is not covered. After talking to the billing department today, it does appear the difference of almost four times the usual cost is due to the different location, it being a university training campus. She did mention the 20% discount or that I have the option of disputing it. Should I ask to talk to a supervisor to see if I can get it negotiated down or do I go through a dispute? Or am I at their mercy and just pay the amount stated?
Robert Farrington says
You can try to get more than the 20% by talking to a supervisor but your path is limited. It’s very frustrating.
Stephen Self says
My wife had a series of eye surgeries four years ago. We paid all our up-front costs, our insurance paid all their part, and we paid the balance on a payment plan. We have paperwork that shows zero balance for all dates of service. Several months months ago, the surgery suite that the doctors used for the procedures was bought by another company, and we started getting bills. They are saying that not all dates of service were paid, and every time we have talked to them we get different numbers of what we supposedly owe. We have reached out to the the eye care center who did the procedures, they said they don’t use that provider any more and cannot help us. We went to the now-renamed surgery center, they said they do not have records. We asked the new owners for itemized billing multiple times, all we get are eob’s. My wife finally sent a signed, dated copy of her patient bill of rights, which guaranteed an itemized bill on request, and the response we got was borderline nasty. They say they have proved we owe the money and have turned us over to collections, for an amount (go figure) that is different from any they have tried to collect from us before. They are wanting a large chunk of change for procedures that we have paperwork showing zero balance on. We are continuing to protest…. Anyone have any ideas? Thanks…..
Robert Farrington says
You might find local lawyers that specialize in medical debt collection. Your state bar is a resource. If you really don’t owe the debt and they continue to contact you, a lawyer might take the case at no cost to you.
Emilie J says
We scheduled my husbands surgery after hearing back from the Dr office that they checked with our insurance and it was covered. We even paid the estimated patient liability of $600 the morning of surgery as we checked in. Now were are 6 months after surgery and receiving bills that are over $10,000 and the insurance saying it’s not a covered procedure. When calling on these bills, we were told that the codes were incorrect and needed to be changed. They were changed and rebilled and still denied. We have just done our first appeal and it was also denied. I plan to file a second appeal. We never would have done the surgery had it not been covered, and I feel the Dr office is to blame. Is our only recourse to take legal action if our second appeal is denied? Please help!!
Robert Farrington says
Appeal but also loop in your state insurance commissioner – especially if you have a copy of the EOB with the estimated patient liability.
Anna says
I had the flu weeks ago which I did a walk-in to a doctor twice because first time, my fever was so high, I didn’t even know until I couldn’t take it anymore. Next was after my fever, my cough was becoming so painful that I kept gagging and starting to vomit that day.
I asked about the co-payment and cost and the medical office claimed that they wouldn’t know the charge until they send it over to the insurance company which was odd to me, but I was really sick and I couldn’t even talk to them properly. I didn’t anticipate a doctor visit to be expensive, but when my bill came in, they charged me around $400 for both visits. If I had known that I would owe $400 for both visits, I would’ve just not went to the doctor at all because they did nothing to help me.
$400 may not seem like a lot to some people, but I make a salary that’s considered low-income in my state and this is putting a huge freaking dent in my finances. I’m already paying $150 a month for the health insurance and I already got ripped off for paying $120 for generic flu medication (which didn’t help because it only works the first 1-2 days of flu apparently). This is beyond ridiculous.
I was better off buying a thermometer and just solving the flu for myself. I feel so ripped off. I don’t have any debt, only bills including rent, and this medical bill piled up so high that I feel completely distraught. I would provide details, but for now, does anyone think I could dispute this or am I being unreasonable?
Robert Farrington says
You’re not going to get far disputing it because they didn’t misrepresent anything. You can check the billing to see if it was accurate. And you can simply ask for a discount. Many places will shave 20-40% off just for asking.
Anna says
Interesting. I didn’t know you could ask for a discount. That’s actually really helpful. Thank you.
Donna says
I had surgery a year ago (last December) and have paid all the charges that were billed. My account with the hospital has shown a zero balance for 6 months. Yesterday, I received bill for another $1,100 worth of charges associated with that same surgery. The hospital did not turn the new billed charges into my insurance provider. How long can the hospital continue to bill me after a procedure? (I’m in Texas.)
Robert Farrington says
Texas, they have up to 4 years to bill you. You can still submit the claim to your insurance – just do that before you pay!
Oľga says
Thank you for your post and information.
I had an emergency surgery last year. One of the incisions was not done correctly and I felt a great pain right after the surgery. The surgeon assumed me that is normal and that it will heal. This was not my regular doctor. After the surgery, I was told that I will need to miss about a week of work. Unfortunately, during checkups the pain was very bad and my regular doctor proceeded with steroid injections to supposedly calm the entrapped nerve. I missed 3 weeks of work. After few months the steroid treatment wore off and the pain returned. Since the incision did not heal properly and I could stick my finger in it, my doctor suggested a repair of the incision surgery. The doctor waived her surgical fee but I got a bill from the hospital for $2000 for the outpatient operating room. I was in the hospital total of 2.5 hours and the surgery was necessary due to a repair of the previous incision. I just received a letter that the hospital is denying my challenge of the bill. How should I proceed?
Robert Farrington says
You can ask for a waiver from the patient advocate at the hospital – maybe explain your situation. However, just because the doctor waived his fee doesn’t mean the hospital waived theirs.
yaima says
Hi, my child is covered with Insurance I took him for high ever to an urgent care then they did flu test and xrays of the loans, they told me it was in-network so it would be $50, this is not the first time I take my son to an urgent care, now I got a bill for almost $700, what went wrong there? If I would have taken him to the ER it would have been $200, I dont understand how come urgent care sent me this bill and without upfront explanation, this is insane. Could you tell me what to do?Thank you so much for this article is really helpful
Robert Farrington says
Follow the steps in the article above. Get a copy of the bill, esnure it was billed correct, so on and so forth.
Mad Mac says
Lots of good advice here. I’ve been dealing with a lot of medical bills over the past two years due to my wife’s chronic poor health, and when disputing one, I do so in writing and make it clear that they will ONLY be dealt with in writing. I don’t call them: by sending a letter rather than calling, it makes it clear that I set the agenda and won’t play their game. About $2000 worth of bills have simply gone away over the past two years through this strategy. I take the view that if they want paid, they will explain just who wants paid and why they want paid, and they will do so to my satisfaction.
One other thing to note is that some bills may say something along the lines of “Payments of less than $50 will not delay any collections activity”. What that effectively translates to is “So long as we get a payment of $50 every month, we’re happy”. Of course, they’re not going to come out and directly say that: the system is set up to obfuscate and confuse.
In summary: accept nothing at face value. If you don’t understand a bill, challenge it in writing.
Richard says
My hospital said my bills where reduced and i did some research and i just realized prices on their procedures where significantly increased so when they said recuced they showed me on bill a bogus savings. And now its just about what it should be. I have the detail billing with charges and bogus adjustment they gave me. My question is what can i do? Is that legal?…If you ask me its fraud.
Thanks
Robert Farrington says
The adjustment is the negotiated rate with your insurance company. All hospitals have “list” prices and then adjustments to the negotiated rate. They also have cash pay rates and adjustments as well, but you went through insurance it sounds like.
The option now is to ask for a discount if you pay all now. Usually you can get another 30-50% if you pay it today.
Robyn says
Thanks for the info: i hav e aunique issue as well. Short summary, MRI done, billed to Cigna, rec’d EOB says cannot bill me, I owe zero. Later got a bill from provider saying I owe the whole thing, as it wasn’t preauthorized. Their fault not mine. They are required to have pre authorization prior to performing the MRI (this I confirmed, laws had changed) was not my responsibility they said. I did begin making smal payments, they sent to collections anyway, even though they were accepting my payment, because they “change their billing system adn purged all the outstanding bills. Again, not my fault. Then when I research a little more and re-read the EOB, I stopped paying, sent them a letter stating why, “I owe nothing” witht he EOB. Heard nothing for a while, then collections. Facility said they were contract with Cigna, I started small payments again, as I didnt want this on credit report. Then found out from Cigna they were contracted and I did not owe this per Cigna. Stopped apying again, sent letter and EOB showing I owed nothing and I was not to be billed their mistake. They are still reporting to credit bureau negatively. Asked Cigna for confirmation in writing they were contracted. Cigna just sent a letter as if I appealed the billing and I was too late and they “upheld” the prior decision that I owe this. Keep in mind I spoke with legal department at Cigna and she told me that the EOB was printed in error that it should have never said I was not to be billed……….ugh, now what…..
Robert Farrington says
If you have the documents you might take it to a consumer law attorney and see if you have any options. A letter from a lawyer can sometimes go a long way to getting this resolved.
Elisa says
Hi!
I don’t know if you still check this, but I am in need of help! I am fighting with ER right now. They sent me 2 bills, one from the Dr. and one from the facility. It was for a laceration and repair. The Dr. labeled it a level 3. The hospital, however, level 5. Hospital will not admit the error. Their coder stands her ground. I am not allowed to talk to a supervisor. I plan to write a formal letter. What else can I do? I think they are upcoding.
Robert Farrington says
That’s normal to get two bills. I would write a formal letter, and then include a copy of the doctor’s bill which shows level 3. Do you know what the description is of level 3 versus 5? Can you get your medical record and see what matches?
Elisa says
No, they would not tell me the descriptions. The lady is very quick to hang up. She just says the coder checked her work and it is correct. The coder works from home. No way of contacting her. I am writing a formal letter. I hope it helps. It was for a laceration repair. From my research, 5 is for a heart attack or something REALLY significant that they have to do a lot of work.
Tobby says
Hi ,
I had an allergic reaction to an antibiotics that I took after the 10th day.. I seek medical help at the ER and was sent home after an hour. No lab work or any further testing done. I was only given steroids oral. I even suggested if there is anything they can give me since I have this reaction 10 years ago and was told that if I become short of breath and got worst I have to come back. I had to come back to ER for the second time the next day, it’s not even 24 hours since I was last seen because I never felt any better since the first ER check. I came back and was even confined for 2 days because It got worst. I got a bill for $150.00 for ER and another $250.00 for confinement billing and I’m sure there’s more bill to come. Can I appeal for the first ER charge since nothing was even done in the first place except for prescribing meds. When I went for the 2nd time, most of the lab result is out of range, so they have to replete the electrolytes, give IV fluids and IV meds for allergy and etc.
Robert Farrington says
No, it sounds like you went to the ER. They can bill you for every time you go there, doesn’t matter than nothing was done. While it might be annoying to hear this, someone still had to spend time on you – checking you in, taking your vitals, talking to you, etc.
Gary Crawford says
I have the exact same situation as Mike on 4/30/2018 and 5/3/2018. After getting an $300 estimate for my out of pocket portion , I chose to go forward with an elective medical scan. I paid the $300 at the time of the scan. The next month, I get a bill for an additional $800. The bill mirrors my EOB from insurance and the CPT codes are correct and match. The issue that others have mentioned above is the inaccurate estimates given. The very definition of estimate is approximation. We are not talking about in or out of network issues or deductibles. We are talking about grossly inaccurate estimates that patients use to decide whether to proceed or not. No one goes on a car lot, buys a car and tells the salesman to just send a bill next month not knowing what the cost of the car was. This issue is now on the national news this week. But no one seems to know how a patient can protect themselves from this or what they can do once it does happen to them. Since I am now the latter, I would like to ask you for your advice please. I have contacted them and they can give no reason for the inaccurate estimate and refuse to negotiate. I am in Texas. Thank you.
Robert Farrington says
Not much you can do, as ridiculous as that sounds. But if you have the documents of a perfect match, I would seriously write a letter to your state attorney general, your state department of insurance, and that health care provider’s CEO. I’d also enlist the help of your local news “consumer report” guy. They might take it up.
If everything lines up clear as day like that, I would raise hell.
As a side note for future readers, never pay in advance! Always ask to be billed.
Susan says
I was told by a patient service representative that my daughter’s heart monitor was covered by my insurance company at 100%. I get the EOB from my insurance company, and it is only covered 20% because the monitoring service is out-of-network, and I am responsible for the balance of $4,950. Unfortunately, I have no written proof of this conversation. How should I approach the health care facility to appeal the bill when I have no proof of what I was told? Or am I stuck with this bill because I foolishly believed what the patient services rep said?
Robert Farrington says
You’re stuck with the bill, but you can always ask to negotiate the cost of it with the health care provider.
evelin fazekas says
Hello, I hope someone is out there to help me out . I’m having an IVF procedure being done , which include a lot of different testing etc. The first estimate I got is about $16,000 plus medication. A couple days later I got an E-mail from the office , saying they made a mistake looking at my last year policy vs this year and actually I have some IVF coverage. Great !! (I suspicious now, so I will call the ins. comp. later, just to find out if I had any change at all or it’s same as last year . Honestly I never called them to find out if I ever had any coverage or not, I’m leaving in Florida is not mandatory so I figured I probably don’t have any, and if I do the ivf office will let me know.) So the new estimate it’s half a price, awesome! But when I compared the original price on both estimate I realized that the second estimate is higher than the first one for the same exact thing before insurance. Example :Egg retrieval comp prof $1780 vs $3200. Embryo transfer $995 vs $1300. Storage,cyro, assisted hatching included at no charge vs $1600. -this last ones actually out of pocket, insurance does not cover it. There is a lot more , also the second estimate is a lot more detailed so I don’t have all the numbers to compare everything ,but clearly all the procedure is priced higher than the first one . So my question is that should I say something, question it, is this normal or just let it go. I don’t want to upset them but in the same time I would like save as much money I can. We are not rich by any means, we work hard for every penny. Thanks Everyone!!
Robert Farrington says
That’s normal because of how they bill insurance and what the negotiated insurance rates are. However, I would call your insurance company as well to make sure, and make sure you get a clear Explanation of Benefits from them in writing before moving forward.
George says
Robert-
First, thank you for writing this guide. Like many others who have commented, we encountered sticker shock recently and I am hoping you can share some advice or insights.
Our son was poked in the eye at an athletic event and suffered a complete hyphema, bleeding in his eye around his iris. We were told by the medical technician at the event that he needed to go to an emergency room, the pressure could build up and result in real damage.
We went to the emergency room at Stanford Hospital (which is a training hospital), where we were immediately taken to a very qualified doctor. The prescribed treatment is eye drops, and the rare instances when eye drops do NOT address the problem surgery may be performed on the eye. They inserted an IV just in case they had to do surgery, and used that to draw blood for blood tests. Eye drops worked, we were there for two hours, and very little was done other than monitoring the pressure in his eyeball and a few rounds of different eyedrops. We went home with eyedrops.
When a bill arrived for $13,712.74 we were more than a little surprised. We called to get the detailed bill, and requested that the codes for the visit be reviewed because no surgery was performed, nothing peculiar was diagnosed, it really should have been a routine $2,000 ER visit with some overpriced eyedrops (that is $680 of the total). We received a letter saying the codes had been reviewed and were appropriate.
As you suggest, we pushed to get the detailed bill again and didn’t give up until we go the service codes. That leads to my question:
1. One line item is service code 62030877, HC Emergency Care Lev5 (HCPCS / RATE / HIPPS CODE = 99285) for $11,522
My research indicates that three things must be true for a Level 5 ER visit:
1. Comprehensive (meaning multiple elements of history)
2. High Medical Decision Making
3. High Severity / immediate significant threat to life for physiological function
For our son, none of these three things was true. The injury was immediate (no history required nor helpful for diagnosis or treatment) and singular (Level 1 = Problem Focused); the treatment is textbook, no thinking required; and there was no danger of death and only a slight danger of permanent damage to his eye.
So … how do we challenge the ER’s decision to code our visit as an ER Level 5 visit when in our perspective it should be ER Level 1?
Thanks in advance for any help you can give us!
Robert Farrington says
Honestly, I don’t know if you will have much luck. What happens is that your case was called Level 5 (severe) at some point, and the hospital activated resources (like getting you to a very qualified doctor). A high level trauma hospital has these doctors available 24/7, which is what you pay for. If you go to a non-trauma hospital, you might not have seen a specialized doctor, and it might not have been billed so highly.
It sounds like you got great care, but short of asking for assistance or petitioning the hospital to reduce it, I don’t think you have much of a case to dispute what they billed it as.
George says
Robert-
Again, thank you. We are able to pay it, and just need some rawhide to bite on as we do so. You are wonderfully kind to provide that for us!
George
R White says
I find your page very informative , its kind of you to share your experience with the public on an area that most of us do not ever bother to inquire into unless we are hit with these type of bills .
I would like your advice on a issue I am currently going through
In 2017 I went in to one of our local hospital for a simple laparoscopic surgery.. (basically an in and out procedure) Shortly after the surgeon came out and told my relative, he was unable to complete the surgery beyond the first incision due to my blood pressure having dropped so dangerously low due to too much anesthesia. I wish I had the time and space to tell you the complications I am left with since then and the amount of times I spent in the hospital and ER rooms. Ever since this hospital has been railroading me to pay them 5,5007 dollars. I don’t know what to do I wrote a letter to them, spoke to numerous personells at that hospital … none the less they sent it into collection and now served me with a court summons.
Would so appreciate your imput
Thank You
Robert Farrington says
If you’ve been sued, you need a lawyer. No other way around that.
G. White says
Hi Robert,
I took my infant daughter in for a sick visit (cough, fever, nothing too scary) and the doctor mentioned running a test that would test for flu and 5 or 6 other viruses. I asked her if she thought it was a good idea and she said that if it was the flu then it was still early enough they could give tamiflu so I said ok. Test results came back and she didn’t have the flu but she did have 2 of the viruses they tested for. No medications were prescribed and nothing changed. Then I got the bill, it was $1,000! I never thought in a million years that a basic panel testing for viruses could run that much. I checked with billing and they say it’s coded correctly. I understand that doctor’s don’t have a price list for tests they run (maybe they should) but don’t they have some obligation to people to inform them when a test is going to be over a certain dollar amount? I certainly wouldn’t have ok’d the test had I known how expensive it would be.
I’ve talked to other parents who’ve said their pediatrician would never run a test like that without letting them know it was an expensive test or that the results wouldn’t really change anything.
I do have insurance, they’re covering $200 of the bill but the rest is out of pocket since it’s a new year and I haven’t hit my deductible. Do I have any recourse? Your advice is appreciated!
Robert Farrington says
Sadly I don’t think you have much recourse. No error, but also no communication – which sucks. I agree, for something expensive like that, a good doctor should at least say “hey, you know this can be expensive”. But, on the flip side, many doctors don’t know the price and/or the amount your insurance will cover.
I think the only thing you can do is ask – and maybe educate the doctor of the price and see if they can help out at all.
John says
Work as a supervisor for the MTA …I have the empire plan..Had acl surgery on my left knee Nov 28th 2018..
Before my surgery I asked the Dr. and the staff if I am fully covered..They said yes.!!!!
I wake up from the surgery in a wheelchair with a big cast on my leg still kind of under anesthesia …..They said to me we are sending you home with an ice machine to use….Ok fine, I sign for it….
2 weeks later they come and take the ice machine…No problem….
Now I get a bill for the use of the ice machine and the cast they used….$1928.00 dollars..
I thought I was covered ?? My ins. co told me why did the Dr go out of network for the cast ? We have many places that will give you the same type of cast and cost nothing….The ice machine is not covered…Yet nobody told me that it would cost upwards of $1,000 dollars to use….I would have said no way, I will use ice packs.Meanwhile I can get the exact machine on Amazon for 160 dollars……Why have me sign this out while I was still coming out of anesthesia ??
I feel I was misinformed….I have great coverage and no one from the Drs. office explained any of this before my surgery….
Do I have a case ? Worse comes to worse I will go to small claims court..
Robert Farrington says
You may have a case on the cast if you had it done in the hospital and didn’t have a choice in providers. You would need to alert your insurance and the hospital. The ice machine is weird, but if you didn’t ask for the price, that is probably on you.
pete says
my wife went for a clinic preventive visit, the insurance had told us that the most we could pay for the first visit is $30 so we had no qualms regarding bill that may arise. Surprisingly we got a bill in the mail for $244 dollars. She phoned in immediately explaining that the insurance company told her she should expect not more than $30, the officer said she would look into it, placed her on hold, came back some moments later to say the insurance rejected the bill so we had to pay.
my wife called the insurance company, they stated that they have had no bill sent for her and with my wife on the line the agent called the hospital, my wife spoke with the hospital staff stating her point and the staff went ” that’s weird, from your record here no bill has been sent to you insurance” she assured that the bill would be sent. with the insurance still on the line my wife reiterated that she is expecting a bill not higher than $30 and the staff acknowledged. A few weeks later we got an explanation of benefit from the insurance : what she owe $0:00
we got a letter in the mail few minutes ago from the hospital stating that my wife has a bill of $244, the leter is dated after the date the insurance received and processed the clam on the explanation of benefit .
I got so angry and came online to find out what i can do, discovered this very informative write up. we be glad if you could advice me please. Is there any resort such that the hospitals do not keep billing arbitrarily?
Robert Farrington says
Glad this helped – hopefully you can get this resolved. The only real thing you can do is file a complaint against the hospital, and maybe with your insurance company that they are incorrectly billing. You might also get local news/media involved to share your story.
Heidi Sanman says
Help please! My daughter dislocated her ankle in 09/18. It was a Sunday, so I wasn’t sure where I should take her for treatment. i contacted the “Ask a Nurse” # on the back of her insurance card. Nearest ER she says. I asked if the closest hospital was on her plan, and after a few moments,”Yes”.
I took her there, she was treated and I didn’t think much about it.
Six weeks later, my husband, who has the same insurance, was having a medical episode that required emergency treatment. My daughter rushed him to the same ER where he was diagnosed with a leaking Type A Aortic dissection requiring immediate emergency surgery. The hospital did not do thoracic surgery, so they ambulanced him to a sister hospital in our city. After an eight hour open heart surgery, he was admitted to their SICU for 6 days, and had a general room for one day.
Two weeks later he had staples removed from groin (vein harvest) and a few days later developed a nasty infection and the site completely opened back up. I took him to the original hospital for antibiotics.
Two months later, the bills started rolling in…appears almost all of his care was out of network. EOBs were produced as if in network and stated that I owed nothing, or a fraction of the original. The providers are ignoring the EOB’s. It took over 5 months for the insurance to release the hospital bill. Our share-$511,000! (Drugs alone for one week was $190K). The emergency room hospital wants $51,000. The doctor, who is in network, was denied as insurance company claims this wasn’t an emergency. Another $15K.
I started the appeals process with the insurance, asking they cover more. I feel that I should get appeals started with the hospitals, but they are also giving me the runaround stating that since my insurance denied, it’s my responsibility.
Now what? Should I just get an attorney now? Not once was I told that my husband was being treated out of network. I expected to pay the max out-of-pocket in-network of $6,750 and the max for out-of-network of $13,300, but now I’m told that I’m responsible for any charges above those the insurance company accepted, and that I can be charged whatever the hospital wants. HELP please!!
Robert Farrington says
Yes, you should appeal. And everything should be capped at your out-of-network max (whether in-network or out-of-network). You should also contact your state insurance regulator if your insurance company is refusing to help.
H says
How can I go about appealing a bill for prescriptions? I am a seasonal firefighter employed by the BLM and my insurance is terminated 30 days after my final work day, usually the last day of October. In this case it must have been 10/27 (the last Friday of the month).
I am now being billed by Blue Cross for the prescription medications I picked up on 11/30. At the time of pick up Walgreens stated that my coverage was still active and valid, therefore my copay was affordable at $80. Had I known that the coverage was not active and valid I would NOT have picked up the rX because the full cost of the medication is not affordable. To clarify, I am uninsured during periods of unemployment – November through April.
Now BCBS is billing me for $2000. Their records indicate that eligibility in the Service Benefit Plan was terminated and the prescription drug claims incurred after the last date of eligibility.
I understand how I can prevent this mistake from occurring again, but I am hoping that I can appeal or file a grievance in this case due to inaccurate approval that occurred when I picked up the rX.
Hopefully the way I explained this makes sense. Any suggestions are greatly appreciated… I don’t even know where to start.
Do I have any options here? Would it benefit me to contact my State Dept of Insurance and request an investigational review?
Robert Farrington says
It was a mistake on your part by missing the deadline by 3 days, which sucks. The only recourse I think you’d have is to definitely appeal and see if they would help as a goodwill gesture. You could also bring publicity to this by contacting your local news consumer help segment, your local paper, or maybe even if BLM Firefighters have a union or trade magazine.
H says
Thank you for the reply. I still do not understand why they paid the claim if coverage wasn’t active. I don’t always know what date the termination documentation was entered as.
Hannah says
My son had spine MRI done at Stanford children hospital(Lucile Packard children hospital). The order was requested by a doctor in pediatric neurosurgery clinic of the hospital.
When I got the bill and the total $22,212 charged by provider really surprised me. The Explanation of Benefits statement shows three charges with same service code and amount, $7,404.00. The total is $22,212.
Insurance paid $12,345.30 to hospital already after discount. But I still need to pay $1,372.71.
Beside the charge for MRI, there was one more bill, $1,410 for Physician who wrote the MRI report. Insurance paid $673.18 to physician after discount, I need to pay $74.8.
I asked hospital why there were 3 charges and were told because there were 3 parts of spine MRI, Lumbar, Cervical, Thoracic. I am not sure why the doctor did such order. My son only have problem in lumbar part.
$23,622 for one procedure in about 60 mins. It is too expensive.
Do you think there is any chance for me to dispute the bill? Your advice is appreciated!
Robert Farrington says
You can pull your medical record and see what the doctor ordered versus what they did. You can also always ask for a discount – usually if you say you can’t afford it, they’ll knock off 30-50% right away if you pay immediately.
Hannah says
Thanks, Will try it.
Karen says
Hi,
I went to an outpatient procedure and the had some pain. The doctor said he was worried that I would have bleeding inside so he wanted to admit me and let me do another blood work in two hours. Without know anything I went to the semi-private room and waited for the blood work (CBC) and got discharged after 3 hours (i.e., 5-8pm I was in the room). I had an ultrasound, and one nurse came in inspected me, and that’s all.
I got a bill around $15,000 and my copay is $1500. I argued this is not impatient, it is emergency. Also it is impossible that a CBC costs $1,700. What’s your insight? Is it possible to change my bill to emergeny (which it was emergency at that time) so that my copay would be $100?
Robert Farrington says
You would need to see what they billed you as and what your medical record states. Pull the info, see the codes, and see if there is anything to dispute based on your explanation of benefits from your insurance.
S D says
Robert
Thank you, I am about to begin this process based on your guidance. I went to an Urgent Care facility to have a splinter pulled from my thumb (I was unable to get it out my self) I was in the urgent care for no more than 5-10 minutes including a pre-blood pressure check. The doc got the deep splinter out quickly, no anasthetic, nothing, just a tweezer and a band aid. I was billed $1200 for SURGERY. Does this sound like something I should dispute? I could have weight loss surgery for $8000…
Robert Farrington says
It sounds pretty normal for the cost. I would double-check the billing for accuracy, but it doesn’t sound unheard of.
Sam says
In our case, we had to rush to the ER and i had called and made sure the hospital we were going to is in-network. After being in ER for a few hours they didn’t allow us to leave and said that our four year old needed immediate assistance due to pneumonia in her left lung and we were moved to ICU. A day in ICU we were told she needed to be operated on to get the fluids out and in comes the surgeon and his team. Now we received an bill for $17,000.00 from the surgeon’s office for their service. How is that the hospital was in network and the surgeon wasn’t? Even then shouldn’t they just accept the amount the insurance would pay to them given the circumstance where they wouldn’t allow us to leave the hospital? $17,000 is a lot of money and it’s very disheartening to see the medical bill! Any advice or tips will be most appreciated. thank you.
Robert Farrington says
What state are you in? This matters a lot – in some state’s it’s against the law for the hospital to be in-network and the doctors not to be (and your situation is exactly why the laws were passed – you don’t get a choice). However, in most states, it’s perfectly legal sadly. In that case, your out of pocket max for out of network applies.
Sam says
New Jersey
Robert Farrington says
Looks like you may have solid ground to dispute it on in New Jersey: https://www.natlawreview.com/article/new-jersey-regulates-out-network-billing
j Roycraft says
Keep fighting this with your insurance company. An inpatient requiring ICU then surgery is unstable and can’t be moved to another facility simply because the surgeon is out of network. During this stressful time who stops to ask the surgical team “are you in network ?” Shame on the hospital and shame on your insurance! Trust me, you can beat this, I was a hospital auditor and dealt with this situation many times.
Mike says
I have a strange case as well.
My wife went to ER last year for abdominal pain, as soon as we went there they assumed it to be appendix and prepared for surgery.
We repeatedly said we need a doctor to examine first before any surgery and they said that’s how they’ll proceed but meanwhile Anesthesiologist was sent to visit us to prepare us for surgery. After some time the surgeon came and he said no surgery is required and it is a case of simple infection and pointed to another doctor who took care of the rest.
After getting discharged from there we received bills and payed them. We also received a note from insurance that they are dropping the coverage for the surgery and it wasn’t required. We didn’t dispute as no surgery took place anyway.
Now, 10 months after the ER visit we are getting a bill from Anesthesiologist for $1700, which after multiple phone calls to them and explaining that no surgery took place they reduced to $700.
We still don’t understand how are we getting charged for a process that did not take place, as no surgery means no anesthesia. He visited us without us consenting for a surgery and performed no action at all.
Robert Farrington says
This is the tough part of going to an ER versus seeing your primary care or going to urgent care. When in the ER, resources are activated for your care – sometimes even before you arrive. You may not end up using them, but you pay for them. The Anesthesiologist did come in, consult, and maybe even prepped for you behind the scenes. You’re going to have to pay for his time. Sounds like you’re on the right track with negotiating it down. I would come back at them and ask if you pay in full right now (say via credit card), would they discount that $700 to maybe $300 and call it settled?
Mike says
Thanks for the response Robert. Appreciate it.
Roshawnda Bell says
Hello Robert,
I was released by my IVF dr at 10 weeks pregnant to go to my obgyn. We set an appointment at 12 weeks. Well at week 11 I went to the emergency room because I was having sever cramps in my lower abdomen and my husband and I was scared something was wrong. So we were seen I refused all blood work except my hgc levels because we had already had labs 2 weeks ago, also refused the urine because we didn’t need that. They gave me tylenol for pain, and fluids. The ultrasound tech came and everything was fine. Well we just received the EOB and we were charged almost 6000, almost the whole thing was wrong. It showed 12 labs, 3 drugs, 2 miscellaneous, emergency room visit 2000. I am so furious. How can they get 12 labs from one hcg. What can I do. I am waiting on the actual bill to compare even if they match i am being billed for services that never took place. Please advise
Robert Farrington says
Emergency care is expensive. The room visit, doctors, etc. You can likely dispute the labs by getting your itemized bill, and comparing to your medical record of that day. See what was ordered and what you are being billed for.
John Standridge says
Robert, your responses are fantastic thank you for all of the advice you are providing.
I was referred to four physical therapy visits from my primary physician in GA. I have a high detectable HAS plan so I always get prices before I do anything. I asked and they said it would be $350 for the first four visits, I confirmed that one payment of $350 would cover 4 visits.
After my forth visit they asked if I wanted to pay off my balance, I told them I was paid in full. They informed me EACH visit was $350 and I had a $1050 outstanding balance. I would have never agreed to this.
What would be the best way to dispute the bill or am I SOL?
Thanks in advance,
John
Robert Farrington says
Yikes, that’s definitely more customer service than billing. I can see both sides here – when you write it as “it would be $350 for the first four visits”, I interpret that as $350 for each of the first four visits – but that’s how my mind works. I can see how you could also think it meant in total for the first four visits.
I would speak to a manager, because for PT, that’s also extremely expensive. I’ve been going to PT for a year for my knee, and it was $200 for the first visit, and then $89 every visit since (2x per month). Note: I also have a HDHP and pay for this 100% out of pocket.
Yulia says
Thank you very much for the article. I was on High deductible plan last year and am about to start my dispute of a $700 bill I received from the hospital outpatient services. I was scheduled for ultrasound that day. Apparently I was billed for a “delivery room” use. I tried talking to billing dept and placed a verbal dispute to which I got a denial as bill justified. Therefore I plan to take matters farther and shake them a bit. Thanks to you I will take it far and really hope to win.
Hayley says
Hello,
I’m so happy to see current replies for comments, hopefully I can get some advise. I have great company insurance that usually pays 80% if not 100% of everything I have done. I got an MRI (my second one ever, had no problems the first time) in February after waiting months for insurance to give approval. The MRI place was busy and scheduled me for a few weeks out from when they finally called me. Weeks after I get my MRI I get a letter that stated what dates my MRI was approved for, but I paid little attention because I already had the MRI. Then I got the bill for about $2,500 insurance had paid $2. I called billing at the MRI place and they said it was an insurance issue, I called insurance and they said I had my MRI after the approved dates and that it was the offices job to ask for an extension of the approved dates because I wouldn’t have known the dates ahead of time. I called billing again and was ignored by multiple people that refused to listen to where the problem was and one even said I had cancelled the original date which is not true I had to reschedule my doctors appointment because he needed to see the MRI (they go through the same office). After having many say they’d call back and never did one lady said she would look into it and fill out paperwork for my insurance. Months of not hearing anything I got a new bill this time with an adjustment of $40ish and insurance paying about $4 I have pretty much the same bill for $2,444 because of a scheduling error. Its a big medical group here in Oregon and I’m not sure its worth fighting. Its a lot of money but a lawyer would be even more especially where I live without knowing if I have leg to stand on or not. This is really stressing me out because I will probably need MRIs at intervals for the rest of my life and it scares me that such a mistake could cost me so much money. Any advise on whether its worth fighting and/or where to begin would be greatly appreciated. Thanks.
Robert Farrington says
You first should appeal it with your insurance company using their approved appeals process. You should also get the pre-approval from your doctor by requesting your medical record and related files.
Second, you should file a complaint with the Oregon Division of Financial Regulation once you have your paperwork. This will usually require a response from the insurance company by law.
Paola says
Hi, Just a quick question. My ob/gyn gave an order for a mri. i did it using my insurance at the same hospital that I work with. I ask the hospital how much i was supposed to pay, they told me that it was cover ( which is not true, i got a 50 dollar bill, which i don’t mind I’ll pay). My hospital is in-network with my insurance. However, i got a bill of $700 from the radiologist doctor who read my mri. This doctor is out-of-network. I did not knew that, I call my insurance and they told me that they would not cover it because the doctor is out-of network. The person who I spoke with, didn’t gave me that much of explanation. i feel frustrated. Do you think that i can do an appeal? i feel like my insurance should pay this or a least some % of it. Thank you.
Robert Farrington says
You can definitely appeal. You can also file a complaint with your State board of Insurance. Many states are outlawing this (sadly, I don’t believe Texas has). You basically don’t get a choice in your radiologist, so how can you even know if they are in-network or out of network? It should be illegal.
Basically, appeal and hope for good graces, and file a complaint. Hopefully if they get enough complaints things will change.
Worst case scenario, though, is you’re on the hook for it.
Teresa Worthington says
Can a hospital charge me for the provider discount they gave to my insurance company? Total charges were $644, provider discount was $263.00 to the insurance company and now they are trying to get me to pay the $263. Is this legal?
Robert Farrington says
You need to look at the explanation of benefits and see what you’re responsible for.
Typically it looks like this:
Hospital Charge: $644
Insurance Discount: $263
Insurance Paid Amount: $118
What You Owe: $263
If the explanation of benefits doesn’t match what the hospital is asking you to pay, then send them a copy and cc your insurance company to get answers.
Nicole says
So long story short my daughter was at an in network hospital for cuts, and needed transferred to a in patient care facility in network. All was fine until I received a bill from the ambulance company, out of network. My daughter has ins thru dad and the state. We finally got the check that was cut from dad’s ins paid to them, but now they are harrassing me about the second amount. My problem with this is I had no choice if she was to ride in an ambulance or not, let alone the company. The customer support is outsourced outside the US and I’m not comfortable giving my social security number. I told them to resubmit the secondary insurance a bill. What can I do if they come back for $932 again? I cant afford to pay it. I’m living paycheck to paycheck. I want to contest the charge.
Robert Farrington says
Sadly, you are likely on the hook for it. I would see if you can setup a payment plan with them, and work with the dad to help with the costs. They also may likely settle for a lot less if you press them on it.
Carrol says
Hi Robert-
My healthy 25 y.o.daughter had a routine physical with a new MD 4/2018. They told her their office did these labs in house to track her health, her insurance covered them and she would have $0 co-pay. She signed papers that stated the same and that if she got a bill she was to bring it to the MD. 9/2019 she gets a bill from a lab for $10000 for genetic testing that was not medically necessary and definitely not described to her on date of service from an out of network lab. Bill was denied by insurance. Bill is not from MD’s office but a lab she’s never heard of. She brought bill to MD who isn’t upholding agreement. MD’s office notes lab is breaking their agreement not to bill patients and they don’t know what to do. The service was deceptively done in MD office but bill is not from MD office who ordered the inappropriate tests and promised nonpayment in writing. Who do we deal with? And how do we make this right? Thx
Robert Farrington says
You deal with the doctor and office that ordered the labs. If you have an agreement, you can take the doctor’s office to court to recoup the costs. You can also review the office, doctor, and others to share your story and take your own business away from them.
Peter says
Can hospital charge upfront before surgery” estimated patient responsibility” with items as follows:
-co-payment
-remaining deductible applied
-co-insurance?
And then not submit it to my health insurance?
Robert Farrington says
The can definitely ask for an up front payment. In my experience, I’ve always refused and said bill me later. They did that. The reason? When you have so many expenses hitting at once, you may be overpaying the hospital if you pay up front.
John says
Hi Robert –
Earlier this year, my son had an accident that severely lacerated his lip. We took him to the urgent care, where the doctor on call stated that he needed a plastic surgeon and sent us to the ER (basically refused service). When we went to the ER, the Nurse practitioner stated that this is not a serious enough cut to require a plastic surgeon and stitched him up with 8 stitches.
Later we received a bill from both the ER and Urgent care. I paid the ER bill but disputed the Urgent care for refusing service. Their billing department stated that the charge was for “new patient administration” to put him in the system. I argued that I came to them for medical care not for them entering his information into their system, and that this was an unreasonable fee considering that they refused service.
I have since had multiple discussions with their billing department, but they won’t remove the charge. They have now sent this to collections. Do you have any suggestions?
Robert Farrington says
Sadly you did go there and got an opinion. Although the opinion was to go elsewhere, it was still an opinion from a medical professional. You’re not going to have much recourse here.
Sraboni says
Hi Robert,
Thanks for your time to respond all these medical insurance related questions. Recently I moved to another state and choose a hospital based family physician and requested for an annual wellness screen. Before I see doctor, I made sure that this is an annual physical exam. One week later I got a statement from insurance stating that visit was a office visit and my responsibility is $300. I called billing, doctors office and the office supervisor, all are saying they are treating as new patient visit and code can not be chaged and blocking me from talking to the doctor directly. They also declined to give me this reason in writing. My question is where is my right to know how my visit will be coaded, who decides and put the code for insurance billing. I made sure the visit is a wellness screen in three different occations, the day I made the appointment, and twice on the day of visit, with front desk and the atteding nurse. Nobody told me that for a new patient, first visit can not be treated as physical. Called insurance and they say if doctor change the code, they will consider. How can I make the hospital change the code.
Robert Farrington says
I would send this with a certified letter to the CEO/CFO of the hospital/organization stating you were told this, and they billed this. Explain the situation, provide records, such as call logs showing your calls, and names of who you spoke to. Depending on your state, if that isn’t resolved, your state’s department of insurance (or some states have departments of managed health or heatlh care) can open an investigation. If you think this is systemic, you can also file a complaint with your state’s attorney general office and share the concern that you believe the hospital is systemically overbilling patients, and provide them your proof.
At the end of the day, it’s $300 – and you may not want to devote so much time over it, as none of these are guaranteed solutions either.
Peter Lopez says
Hi Robert, thank you for what you’re doing here. It is great help for people/patient to be equipped to navigate though this broken medical billing system.
Hi Sraboni, if Robert approves this advise (not as legal counsel or anything), feel free to do so. I work as medical billing specialist who is also a certified coder (CPC by AAPC). The easiest way you can tackle this without spending so much time would be, contact your insurance patient customer service and ask for assistance, am not sure what insurance you have but I had received calls in the past where patients had issues with their bills and asked their insurance to call us and I dealt about several calls and most of them were resolved but this definitely depend on the biller’s knowledge. I would also request for the medical records, if the documentation states that it was a problem-oriented visit (99201 – 99205) rather than wellness exam/visit (99385 – 99387) or it might be even both if “you” presented a problem or the provider found an abnormality in the course of the wellness exam, then, they can bill for both wellness and problem-oriented visit to your insurance (there are strict billing guidelines by regarding this to prevent providers form abusing this). From the looks of it, the $300.00 might have been charged to your deductible which is still pretty high for a problem oriented visit unless your insurance processed your claim as out-of-network (OON). Let me know.