Sudden medical expenses can arise after an ambulance ride, emergency room visit, sudden hospitalization, or unplanned surgery. In fact, they can even come up after a planned doctor’s visit or medical procedure.
Whether you couldn’t shop around before receiving care or a provider billed you for charges you didn’t foresee, surprise medical bills are a common problem in the United States. Health care pricing isn’t transparent, and the uncomfortable truth is that complexities of health insurance networks and covered services frequently leave Americans with bewildering bills.
If you’ve found yourself or a loved one dealing with this problem, the following strategies could help you eliminate unfair charges and manage legitimate ones.
- Request itemized bills.
- Appeal denied claims.
- Dispute unreasonable charges and negotiate.
- Enlist help from medical billing experts and advocates.
- Look into state protections.
- Learn your rights under the No Surprises Act.
Request itemized bills
Ask your providers to give you itemized bills, not summaries. Review them line by line for mistakes. For procedures you weren’t conscious during — where it’s hard to know if you’re being billed accurately — request copies of your medical records and compare their notes against your bills.
When reviewing your bills, look for:
- Incorrect dates of service.
- Duplicate charges.
- Fees for services or medications you didn’t receive.
- Unreasonable charges.
Also, compare your bills against the explanation of benefits from your health insurer (or your Medicare Summary Notice if you’re insured by Medicare) to make sure they match. If they don’t, your insurance coverage might not be applied correctly.
If you don’t understand your bill or your explanation of benefits, you’re not alone. Try looking online for the medical billing codes the provider used and see if they make sense for the care you received. Don’t be afraid to ask your provider or their billing department, as well as your health insurer, to explain your bills to you step by step.
You may feel like they have the upper hand, but remember that you’re the customer. You deserve to be billed accurately and to understand what you’re paying for.
Appeal denied claims
In a study of health insurance claims denials and appeals using HealthCare.gov data, the nonprofit Kaiser Family Foundation found that insurers denied 17 percent of in-network claims — that’s 48.3 million claims — in 2021, the most recent year for which data were available.
Excluded services are a common cause of denials. Another is lack of prior authorization or required referral. Incomplete information is another reason claims get denied. Only 2 percent of denials were based on lack of medical necessity, according to the Kaiser study. Consumers appealed about 1 in 10 denied claims; among those who appealed, 2 in 5 won.
The best way to appeal may depend on the cause of denial. If your provider used the wrong billing code, they can resubmit the bill to your insurer with the correct code. Appealing an incorrect bill won’t get you anywhere. Nor will appealing a denial for a service your plan doesn’t cover. If your original claim was missing information, follow your insurer’s directions for providing the additional information required to review your claim.
The Patient Advocate Foundation publication “Engaging with Insurers: Appealing a Denial” offers details about how to handle the appeals process.
Dispute unreasonable charges and negotiate
Prices for the same medical services vary substantially by provider. In particular, any service can be much more expensive in a hospital than in a doctor’s office, lab, or outpatient facility.
One way to pay a lower fee on a service that isn’t covered (or isn’t fully covered) by your health insurance may be to negotiate using other rates in your area as evidence. Compare what medical providers bill you with costs published by sources such as ClearHealthCosts, FAIR Health Consumer, and Healthcare Bluebook (available through some employers).
In the event that someone was facing an unreasonable medical bill, “I would suggest they contact the provider and try to negotiate,” said Eric Tom, senior financial services executive with Blue Ocean Wealth Solutions, a MassMutual firm.
If you learn that a fair price for emergency transportation by ambulance with basic life support in your ZIP code is $2,235 for out-of-network or uninsured customers, you might be able to use that figure as leverage against a $4,500 bill by asking the provider to match the price your research uncovered.
If you’re being charged an out-of-network rate, ask the provider to bill you for the negotiated rate that they bill their in-network insurers, or for the cash rate that uninsured patients pay. You may also be able to negotiate a discount by offering immediate payment in cash.
If all else fails, ask for a payment plan. Spreading out your payments over time can make them more manageable and help keep your medical bills out of collections while you look for other payment solutions.
Enlist help from medical billing experts and advocates
Sometimes, dealing with sudden medical expenses on your own is just too overwhelming, especially if you’re sick or caring for a loved one. It’s a common situation to face, and many resources are available to help. Here are a few:
- Medicare Rights Center. This national nonprofit serves consumers by helping older adults and people with disabilities navigate the Medicare system through their free national helpline.
- National Association of Healthcare Advocacy. Use this organization’s advocate directory to find professional healthcare advocates you can hire for assistance.
- Alliance of Claims Assistance Professionals. This organization vets claims assistance professionals who help with insurance claims and patient advocacy.
- The hospital’s patient advocate. If your bill is from a hospital, ask to speak with the hospital’s patient advocate. If the hospital has one, this individual can help you deal with your bills and insurance provider.
- Your employer. Patient advocacy may be a benefit you’re eligible for through work.
Additionally, a financial professional may be able to offer some suggestions for help and building a financial strategy to cope with the expenses. (Need a financial professional? Find one here)
Look into state protections
Many states have passed laws to protect consumers against at least some surprise medical bills. For example, a New York law protects consumers against surprise bills from out-of-network providers when they’ve been treated by an in-network doctor or at an in-network hospital or surgical facility. This law is designed to address large bills that can result from circumstances like:
- You received the services of an out-of-network anesthesiologist or surgical assistant you weren’t able to foresee or choose during surgery.
- Your in-network doctor or facility sends a lab specimen, X-ray, CT scan, or MRI to an out-of-network pathologist or radiologist.
- An ambulance takes you to the nearest emergency room and it’s not in your network. (Related: Living Mutual: The emergency room)
However, even if you live in one of these states that offer consumer protections against surprise medical bills from out-of-network providers, the law may only apply if you have a certain type of plan.
Learn your rights under the No Surprises Act
The No Surprises Act applied protections at the national level that were only available to certain consumers in specific states. Almost all employer health plans and individual health plans are required to follow this new law, which took effect in 2022.
If you visit an in-network hospital or facility, your insurance provider will have to cover unexpected out-of-network charges so that you are only responsible for what that service would have cost had it been in network. Out-of-network providers won’t be allowed to bill you for the difference between their bill and what your insurance pays, a much-decried practice called “balance billing” that lies behind many surprise bills.
The No Surprises Act is not perfect, though. It does not apply to short-term insurance plans, uninsured individuals, or ground ambulance services.
“I learned early on in life through my parents that health insurance is a must — it is definitely not worth taking a chance, because accidents and unexpected health problems are inevitable,” Tom said.
Yet, even with health insurance, surprise medical bills can range from minor annoyances to major threats to our financial stability.
It may require tremendous patience, perseverance, the kindness of strangers, and even hiring professional assistance. But you can get through this challenge. There are people who will help if you know how to reach out.
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