Even when you have insurance, you’re not always covered.
An unexpected surgery, outpatient procedure, or ER visit may come with unforeseen medical bills. Nearly a third of Americans have gotten a medical bill they didn’t expect. For 43 million Americans in 2014, these and other bills led to medical debt reported to the credit bureaus, according to the Consumer Financial Protection Bureau.
How do you deal with a surprise medical bill you didn’t expect (and might not even understand)?
1. Review the bill carefully and check for mistakes
Hospital billing departments handle a lot of data. It’s surprisingly common for bills to have errors. Around eight out of 10 hospital bills contain mistakes. You may be billed for a service or procedure you didn’t actually receive. Your bill may have the wrong date, or the provider might have inaccurate insurance information for you.
Even for treatment you did receive, the charges for specific items sometimes seem unusually high. Your insurance may cover certain medication brands, for instance, but not others. There could also have been changes to your insurance policy. These surprise changes are a good reason to stay on top of the mail and info insurance companies send, even while you’re healthy.
Your bill should be itemized, with each service and price listed individually. If the bill isn’t itemized, request one that is from the hospital billing department. Question charges like multiple readings of scans or tests (you should only be charged for one) and hospital-provided items like blankets and gloves (which should be included in the facility fee).
Hold onto the bills and all information you received from the hospital. Record phone calls, including who you spoke with and when, and keep any relevant e-mails. A paper trail will help you make your case.
If you got an advance estimate—before elective surgery, for example—and the bill goes over the estimate, ask your insurer why. Then find out if your healthcare provider will accept the original lower rate.
2. Learn about balance billing and whether it affects you
What if you receive a hefty bill from a doctor you don’t remember seeing? If you’ve ever been treated at a hospital or had surgery, you’ve probably dealt with plenty of medical professionals, from nurses to anesthesiologists. And plenty more are working behind the scenes on your care.
If any of these providers are out-of-network (not covered by your insurance plan), they’ll bill at a higher rate. Even if your primary doctor and facility are in your insurance network, you may also be treated by someone who isn’t—and billed accordingly. That means your insurance doesn’t cover the full cost of your procedure, leaving you with the outstanding balance.
This practice is called balance billing, and it happens a lot.
- Some states have legislation to protect consumers from surprise medical bills and some don’t. There’s no federal legislation regarding balance billing. However, about a quarter of states have laws on the books, and more states are working towards protections.
- If you live in California, Illinois, Florida, New York, or Connecticut, you’re covered; your state may require providers to charge the in-network rate, even if they’re out-of-network.
- More states protect customers with HMO (Health Maintenance Organization) coverage, especially in an ER billing situation, than customers with PPO (Preferred Provider Organization) coverage.
- Research your individual state insurance regulators to learn what protections, if any, the state offers from balance billing.
3. Communicate and negotiate with your care providers
Get in touch with your insurer, doctor, and hospital as soon as you can.
Ask your insurer for detailed information on each itemized charge, especially charges they declined to cover or charges that seem excessively high. You can ask the insurance company to negotiate with your doctor or healthcare provider for a lower rate.
You can negotiate an excessive balance bill, too. First research what the service or procedure you were billed for typically costs. Then ask your health care provider if they’re willing to charge the typical market or in-network rate. Find out which charges on your itemized bill are negotiable.
4. Ask for a payment plan or financial aid
Let’s say you appeal the charges and they’re determined to be valid—your insurance company won’t pay any more than the amount stated on the bill. The next step is to request a payment plan with little to no interest. Most billing departments will have payment plans available. This is a better option than putting a huge charge on your credit card which you’ll struggle to pay off.
Find out about any charity care or financial aid programs the medical facility offers, as well. These programs are especially helpful if you’re uninsured or underemployed. You’ll need to provide financial data like proof of income and bank account statements in order to apply for aid.
Appealing a medical bill can take time. Stay calm and make sure your doctors and providers know where you are at each step in the process, so you don’t get a surprise collections notice. With planning and communication, you can end up paying a lot less than the original bill.
5. File an appeal with the insurance company
You can file a formal appeal, or complaint, with your insurance company—or the state insurance regulator if your appeal is denied. Medical bills often come with instructions on how to appeal the charges.
Meanwhile, tell your doctor you’re disputing the bill with your insurer. Ask them not to send the bill to collections if possible. Note that doctors aren’t obligated to refrain from sending delinquent or overdue bills to collections.
In order to dispute a bill, you’ll need a written notice and any documentation that will back you up, like records from the doctor’s office. Make copies to send and hold onto the originals. Medical Billing Advocates of America is a good resource if you’re overwhelmed by the dispute process.
Medical procedures are scary enough without worrying about an unexpected bill. If you do find yourself unexpectedly charged, there are ways to appeal the charge. If your appeal isn’t successful, you have options for paying it back that won’t wreck your budget or your credit.