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Fix medical billing errors with this 6 step process

People reading their medical bill

Got a medical bill that just doesn't look right? Here are 6 steps for identifying medical bill errors and what you can do to fix them.

The last time you got a medical bill, how closely did you look at it? If you just paid it and moved on with your day, it’s OK. Medical bills can sometimes be confusing.

But if something seems off, it’s worth digging into. There could be a billing error that’s causing the amount to be more than it should be.

Something as simple as a typo can cause billing errors. In some cases, you may be charged for care you didn’t get. Or accidentally charged for the same service twice. But how can you know if there’s an error on your medical bill? Follow these six steps to find and correct medical billing errors.

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Step #1: Know what your health plan covers.

Understanding what your health plan covers is the first step. Here’s what to check:

  • Start by reading over your plan’s summary of benefits and coverage. You likely received this info when your plan started or renewed for the year. But you should be able to find it online too. It explains what your plan covers, and what it doesn’t. It will also detail any limitations on types of medical services.1 For example, your plan may cover only a certain number of physical therapy visits.
     
  • Check your plan’s care provider network. Your health plan may only cover care from certain network doctors and other health care providers. Or they may charge more when you visit a provider who is not in-network.2 Your plan’s website likely has a directory where you can search for network providers.
     
  • Know your deductible, copay, coinsurance and out-of-pocket limit. Here’s what those are:
    • A deductible is the amount of health costs you are responsible for before the health plan starts sharing costs.
    • A copay is the fixed amount you pay each time you see a network provider.
    • Coinsurance is the amount shared by you and your health plan for health costs, calculated as a percentage.
    • An out-of-pocket limit is the total amount of health costs you are responsible for before your plan pays 100% of covered health costs for the rest of the year.
  • Check your plan’s list of covered drugs (formulary). It also explains how much you’ll pay for different medications.

You’ll want to go over this information every year. Health plans may change their coverage each year.

Step #2: Estimate your costs before you get care.

Do you plan to have a screening test or medical procedure done? There are ways to get an idea of what it might cost ahead of time. First, ask your doctor what exactly they are ordering. Talk to the billing office, too, and ask for the billing codes. Those are what your provider will use when submitting a request to your health insurance company asking for payment (a claim).

Once you have the billing codes in hand, you can ask your insurer what and how much they will cover. Your insurer may also have a “cost estimator” tool on their website that you can use. It can give you a cost estimate based on what care you need and where you are getting it.

Or you can call or email someone directly at your health insurance company. Ask what you can expect to pay out of pocket. You’ll want to get this in writing so you can compare it to your bill later.

You can also ask for a “good faith estimate.” That’s when your doctor or the facility where you’re getting care gives you an estimate of the expected charges. Providers must give this to you if you don’t have insurance. They must also give it to you if you plan to pay for your care without insurance.3

Hold onto that estimate so you can compare it to your bill later. If the actual bill is $400 or more above the good faith estimate, you may be able to dispute it.3

(Recommended reading: Can I deduct medical costs from my taxes?)

Step #3: Check the paperwork you receive after a medical visit

After you get your care, you’ll get paperwork from both your care provider and your insurer. Your provider will send you a bill that you’ll need to pay. You may get more than one bill. For example, if you had surgery, you may get separate bills from the facility where you had the surgery and from the doctor.

You will also get an Explanation of Benefits (EOB) from your insurer. The EOB is not a bill. It is a form that explains:4

  • What services you received and what your insurance covered
  • What your insurer paid (or will pay)
  • What you owe to the care provider (this amount should match the bill you get from your provider)

File the EOB with your other bills and hold onto them for your records. If any information on the EOB doesn’t match the bill from your provider, call your care provider or insurer. They can help you understand your bill. Many hospitals have financial counselors that can help.5

Step #4: If you think there is an error, act quickly.

Look over your bills and EOB carefully. Compare them to the estimates you received beforehand. If anything seems off, call your provider or insurer right away. You may need to talk to both.

If you get a bill from an out-of-network provider, talk to your insurance company. You can start by calling the number on the back of your insurance card.

The No Surprises Act protects you from being charged more for out-of-network care if:6

  • You get emergency care from an out-of-network provider or facility.
  • You get care from an out-of-network provider at an in-network facility. (For example, if you got surgery at an in-network facility, but the doctor providing sedation was out of network.)

If you suspect you’ve received a billing error, you won’t want to wait to talk to your provider or insurer about it. You may have as little as 30 days to pay the bill. After that, it could go to collections. And an unpaid medical bill that is $500 or more can impact your credit score.7

Step #5: Get help for medical billing disputes.

If you aren’t having any luck talking to your insurer or care provider, there are other support options. You can submit a complaint online to the Centers for Medicare and Medicaid Services or call the No Surprises Help Desk at 800-985-3059.8

They can go over your complaint to make sure your insurer and provider followed the surprise billing rules. If they can’t answer your question, they will refer you to your state’s Consumer Assistance Program.

If you get your insurance through your employer, check with your benefits department. They may have people that can help with medical billing issues.

You can also seek help from a medical billing advocate. They can go over your case and help negotiate with your provider or insurer. They may charge an hourly fee or take a percentage of what they save you. The Alliance of Health Advocates has an online directory where you can search for a billing advocate near you.

Step #6: Try negotiating your bill.

If you can’t dispute a charge, you may be able to negotiate. Check online resources like FAIR Health or Healthcare Bluebook to figure out prices in your area. If you were charged more than the fair price, ask your provider if they can lower their fee.

If that doesn’t work, you can ask for a payment plan. You’ll pay off your bill through a series of payments over a period of time.9

You can also ask about financial help. The Affordable Care Act requires that nonprofit hospitals offer “charity care.” This is free or discounted health care for people who need help paying their medical bills. Many for-profit and private hospitals also offer charity care.10

Ask about your hospital’s financial assistance policy to see if you qualify. You’ll likely have to fill out an application with details about your income.

If you’re on Medicare, you may be able to get help with your bills through a Medicare Savings Program. These programs may help pay your monthly health care premiums as well as deductibles, copays and coinsurance. Contact your state here to see if you qualify.

Dealing with medical bills can be stressful. But the time and effort could save you money.

Sources

  1. Centers for Medicare and Medicaid Services. Summary of Benefits & Coverage & Uniform Glossary. Accessed April 18, 2023.
  2. U.S. Department of Health and Human Services. What you should know about provider networks. Revised February 2022. Accessed April 18, 2023.
  3. Centers for Medicare and Medicaid Services. No surprises: What’s a good faith estimate? Accessed April 12, 2023.
  4. U.S. Department of Health and Human Services. Reading your explanation of benefits (EOB). Published May 2022. Accessed April 12, 2023.
  5. MedlinePlus. Understanding your hospital bill. Reviewed August 11, 2022. Accessed April 12, 2023.
  6. Consumer Financial Protection Bureau. What is a “surprise medical bill” and what should I know about the No Surprises Act? Reviewed February 2, 2022. Accessed April 12, 2023.
  7. Consumer Financial Protection Bureau. CFPB Publishes Analysis of Potential Impacts of Medical Debt Credit Reporting Changes. Published July 27, 2022. Accessed April 13, 2023.
  8. Centers for Medicare and Medicaid Services. Complaints about medical billing. Last updated February 14, 2023. Accessed April 13, 2023.
  9. Consumer Financial Protection Bureau. What should I know about medical credit cards and payment plans for medical bills? Reviewed February 2, 2023. Accessed April 12, 2023
  10. Consumer Financial Protection Bureau. Is there financial help for my medical bills? Reviewed June 10, 2022. Accessed April 12, 2023.

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