Health insurance counseling

Navigating surprise medical bills

CVC Case Manager Tomi Vega is a certified application counselor under the Affordable Care Act as determined by the Centers for Medicare and Medicaid Services.

Nearly one third of Americans have received medical bills they didn’t expect, according to the Consumer Financial Protection Bureau. Forty-three million Americans received surprise medical bills in 2014 related to unexpected surgery, outpatient procedures, or emergency room visits that led to medical debt reported to the credit bureaus.

You can prevent some surprise bills by verifying insurance coverage and asking for an estimate of your expected costs for services in advance. But more and more often, bills are surprising people, despite efforts to verify coverage in advance.

We collected five tips for avoiding and navigating surprise medical bills.

1. Review the bill carefully and check for perceived billing mistakes, or charges that don’t seem quite right.

Doctor offices and hospital billing departments manage a lot of data. As a result, roughly eight out of 10 medical bills contain mistakes. Two common errors are billing someone for a service or procedure they didn’t receive and using inaccurate insurance information.

To help with this process:

  • Confirm that your provider has accurate insurance information each time you visit, particularly if you have more than one insurance policy.
  • Hold onto bills and any other information you receive from the provider, including through email.
  • Keep track of who you speak with and when—as well as any other communication. A paper trail can help your case if there is a disagreement later on.
  • If you received an advance estimate of a procedure’s cost and the bill goes over the estimate, it’s best to ask why. You or your insurance can inquire whether your health care provider will accept the lower rate originally agreed upon.

2. Consult and negotiate with your health care providers.

Get in contact with your insurer, doctor, or hospital as soon as you can. Obtain detailed information including an itemized statement showing each charge. You can negotiate with the provider for a lower rate, especially for charges that were not covered or for charges that seem unreasonably high.

Research the typical cost of the procedure or service you received. Know the in-network price or the average cost of a service. Sites like Fair Health Consumer and Healthcare Bluebook can help you find this information.

3. Appeal or file a complaint about charges that don’t meet your expectations.

You have the right to file a formal appeal with your insurance company if coverage was denied or you feel you were incorrectly charged out-of-network. Medical bills generally come with instructions on how to appeal the charges. While you file the appeal with your insurance, inform your doctor you are disputing the bill with your insurance company. Request them not to send the bill to collections, if possible.

Important note: Though you have the right to ask, doctors are not obligated to refrain from sending delinquent or overdue bills to collections.

If you believe you have been improperly balance billed, you can file a complaint with your state insurance regulator. (Learn more about balance billing here.)

In order to dispute a denied service or unreasonable bill, you need to submit a written request. Collect any paperwork related to the disputed charges from the provider and medical records that can help you create a strong argument. Make copies to send and keep the originals.

Resources to help:

4. Request a payment plan or financial aid.

If you dispute billed charges and the provider determines they are valid, you will owe the amount stated on the bill.

Contact the billing department to discuss your payment options. You can request a payment plan with little to no interest. This is a much better option than putting a huge charge on a credit card which likely has a higher interest rate and will be much harder for you to pay off.

Also ask about financial aid programs the medical provider offers. These programs are especially helpful if you’re on a fixed income. You’ll need to provide financial records like proof of income and bank account statements in order to be considered for financial aid.

If you have the resources to pay a significant portion of the owed amount all at once, you can usually negotiate a reduced amount in exchange for an immediate one-time payment. A provider may accept half of the owed amount as payment in full if you can pay all at once, right away.

Remember, appealing or negotiating a medical bill can take time. Stay calm and make sure to communicate with your health care providers at each step in the process. If you understand your coverage and rights and take the proper steps to dispute charges you feel are inaccurate or unreasonable, you can avoid surprise bills or pay a lot less than the original bill.

5. Understand the common practice of balance billing.

Many billing mistakes happen through a practice called balance billing, which generally means you’ve been billed for charges beyond what your insurance company agreed to pay. But the concept and why it’s worth knowing is complicated enough that we described it in its own blog.

To understand more about balance billing and how it could impact you, check out part one of this surprise bill series: “Understanding balance billing and when it’s not legal.”

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