How to Appeal a Medical Bill

The Medical Billing Advocates of America reported that 9 out of 10 hospital bills have errors in them, most of which benefit the hospital.^{[1]XResearch source} If you receive a bill that seems excessive or in error, you should immediately begin to address the potential issue. This begins with determining if there was an error or an intentional denial of coverage, disputing the charges and ultimately either negotiating the payment of the bill or appealing the insurance company's denial. While this is a time consuming and often frustrating process, by successfully challenging a medical bill you may be able to save yourself a significant amount of money.

Part 1

Part 1 of 3:

Questioning an Excessive Bill or a Denial in Coverage

1
Review your bill. As soon as you receive a medical bill in the mail, it is important to review the bill for inaccuracies, such as being billed for a procedure that you did not receive or for excessive costs (discussed below). If the bill is for services that you received and the bill was not submitted to your insurance company, you should immediately submit the bill to your insurance company. If you received the bill because your insurance company refused payment, you need to review your insurance policy.
- If you do not have insurance, you should immediately request an itemized bill, as discussed below.
2
Review your insurance policy. If you have insurance and your insurance refused to pay your medical bill, you need to review your policy to determine what your plan covers. Typically, an insurance company will notify you or the medical provider submitting the bill of the reason that coverage was denied. This information may be conveyed in the bill you received, in a letter from your insurance company, or you may need to contact the medical provider and ask what reason they received for the denial. You should then review your policy to see whether your medical treatment is covered by insurance.
- Check whether the bill is for a co-pay or a coinsurance amount that you are required to pay under your plan. For example, under some plans individuals are required to pay for a percentage of the total cost of the procedure.
- Determine whether you have a deductible that you must meet before the insurance company begins paying on claims. Some deductibles can be thousands of dollars and you would be required to pay that amount.
- Determine whether the physician or the procedure was excluded under your insurance policy. For example, some insurance companies will only cover treatment from in-network medical providers. If you see someone outside of the plan, you may be responsible for the entire cost of the treatment.^{[2]XResearch source}
Once you have reviewed your policy, you should have a pretty good understanding of whether your medical treatment should have been covered by insurance. If you feel that you were improperly denied coverage, you need to determine if your coverage was denied because of a mistake, such as an incorrect billing code, or if the insurance company is intentionally denying your claim. In order to make this determination, you need additional information from your medical provider.^{[3]XResearch source}
4
Request an itemized statement. Generally, when you receive a bill from a hospital or medical provider, your bill will indicate the date of the procedure, the place of the treatment, and the medical provider. In order to challenge a medical bill, you need to request a bill that details every charge, individually. This will include charges for every medication your received, test that was run, and service that was provided.
- Medical providers are legally required to provide you this document.
- If the statement contains codes that you don't understand, call the billing office for the provider that sent the bill and ask for an explanation.
- You can often find the explanation for codes online by conducting a search for the billing code or abbreviation followed by “CPT.”^{[4]XResearch source}
5
Review the itemized statement for errors. Once you receive the statement and determine what each code means, you need to review the itemized bill for errors. Go through each item individually and highlight anything that looks suspicious. Some of the most common billing errors include:
- Double billing, which means you were charged twice for the same service or treatment.
- Typos in the billing codes or in the dollar amounts.
- A charge for a test, service or treatment that was ordered but never performed.
- Inflated charges for medications or supplies.
- A mistake in the amount of days you were at the hospital. Most hospitals charge for the day you were admitted but not for the day you were discharged.
- A mistake in billing you for a private room instead of a shared room.^{[5]XResearch source}
6
Research the cost of charges that seem excessive. If you came across costs that seemed very high, you should compare the cost of the service on your bill to other providers in your area. There are free websites that allow you to easily compare the cost of services.^{[6]XResearch source}
- Healthcare Bluebook offers a free online cost estimator.^{[7]XResearch source}
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Part 2

Part 2 of 3:

Challenging the Bill and Negotiating the Cost of Service

1
Contact the place that sent you the bill. Once you have gathered your information, examined the detailed bill, and researched the excessive costs, you should call the office that sent you the bill. When you call the office, ask to speak to the billing office and tell the person that you have a question about your bill.
- Once you are on the phone with the billing office, explain that you are calling about a bill that you received.
- Confirm whether the bill was submitted to your insurance company, and if so, verify the reason that coverage was denied.
- Tell the person that you reviewed your itemized bill and have some questions about the charges.
- If you found mistakes, explain the mistakes that you found.
- If a charge was excessive, ask the person to explain the charge and explain why you think it is excessive.
- Most often, unless there was a simple coding mistake, the billing person will not be able to correct your problem immediately.
- If there was a coding problem, ask them to correct the problem and resubmit the bill to your insurance. If you do not have insurance, ask them to send you a corrected bill.^{[8]XResearch source}
From the first phone call that you make about disputing the bill, you need to take detailed notes about: who you spoke to, including his or her name and contact information; what he or she said; and what, if anything, he or she was going to do next.^{[9]XResearch source}
3
Follow up with a letter. You want to follow up your conversation with a detailed letter that specifically states that you are disputing the bill. Your letter should also reference the conversation that you had with billing office, including the date of the call, the name of the person with whom you spoke, and any action that he or she was planning to take. You should fax the letter and mail it, return receipt requested, to the billing office that sent you the bill. By sending a letter, you ensure that if the bill is sent to collection, the bill must be noted as disputed. Your letter should include the following:
- Your name, address, and contact information.
- The date of the bill and any billing identification number.
- A detailed explanation of why you are disputing the bill. If you are disputing a billing error or code, set forth the specific code and the reason why it is incorrect. If you are challenging an excessive charge, explain what the cost of comparable services in the area.
- Detail any conversation that you have already had with the billing office.
- Be specific on how you want them to rectify the situation.^{[10]XResearch source}
4
Negotiate the amount you owe. If after reviewing your bill, researching the costs of comparable services and your insurance coverage, you feel that you may owe the medical provider a fee for services, you can try to negotiate for a lower cost. Sometimes medical providers will bill insurance companies at a higher range of the cost of care but are willing to accept less money for a patient. Most often, a doctor does not handle any of his or her own billing and therefore you should not be worried that negotiating the cost of services will impact the medical care that you receive.^{[11]XResearch source}
- Speak with the billing office and explain your financial situation and that you are going to have to pay for the care out of pocket.
- Ask whether they would be willing to reduce the bill.
- Ask if you could pay your bill on a payment plan.
If you have a very large bill that you are unable to pay, you may want to consider hiring a medical billing advocate who will negotiate on your behalf with medical providers. These advocates will dispute the bill, raise any errors and negotiate for a lower fee. Generally, these advocates charge $35 to $200 an hour. Some advocates take a percentage of the amount that they save you in the bill.^{[12]XResearch source}
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Part 3

Part 3 of 3:

Appealing an Insurance Company's Continued Refusal to Pay

1
Decide whether to file an appeal. If after reviewing the itemized bill and speaking with the medical provider, you determine that charges were not for a billing or processing error but rather a refusal of payment by your insurance provider, you will need to appeal directly to your insurance provider to overturn their decision. You then have to determine whether you want to file an appeal. If you think that you have a strong argument to be made on why your insurance company should pay your claim, you can move forward with the appeal.
- If your policy clearly states that the procedure wasn't covered and you can't prove that the procedure was medically necessary, your time may be better spent negotiating directly with the medical provider for a reduced cost for services.
If you have not already received a letter from your insurance company explaining why it denied payment, you should contact the insurance company, ask them to review your case and request a written explanation of why coverage was denied. Even though you may already have this information from speaking with your doctor's office, you want to have written confirmation from your insurance provider.
The denial letter will explain the insurance company's specific reason for why coverage was denied and the provision in your policy that supports its determination. The letter may also indicate what information the insurance company may need to overturn its decision. Lastly, the letter should detail the insurance company's appeals and grievance process, including the date by which you need to submit your appeal and where and how to send your formal appeal.
4
Talk with your medical provider's office to let them know you plan to appeal the denial. If you decide to move forward with the appeal, you should inform your medical provider. The medical provider is under no obligation to wait for the outcome of your appeal. He or she is entitled to be compensated for services rendered. You have three options on how to handle your outstanding bill.
- Delay paying the bill until the appeal has been decided. If you choose this option, you should ask your medical provider not to send the bill to collections. However, your doctor can choose to send the matter to collections.
- Establish a payment plan, where you are paying enough of the bill so that it isn't sent to collections.
- Pay your bill and seek reimbursement by your health plan if you win the appeal.^{[13]XResearch source}
If you decide to move forward with the appeal, request that the insurance company provide you with all of the information it relied on in making its denial. This will allow you to craft a stronger and more tailored appeal.^{[14]XResearch source}
6
Draft your appeal letter. Your appeal letter should be well organized, persuasive and fact based. You want to specifically address the reasons why your claim was denied and provide specific reasons and evidence why the insurance company was incorrect. You want to make sure that you submit your appeal by the deadline and in the manner that the company established for appeals. Specifically, your letter should include:
- Your name, address, and contact information.
- The letter should be addressed to the specific person or department that handles appeals and the correct address.
- Provide specific information from your plan that supports why the insurance company should overturn its decision.
- Identify your plan, insurance number, and the your insurance claim number, if you were assigned one.
- Include a copy of your insurance card.
- A statement that identifies the decision that you are appealing.
- A description of where you are in the appeals process.
- A description of how you want the case to be resolved.
- An explanation of why you are appealing, including all relevant facts and supporting information.
- A courteous closing statement and your signature.^{[15]XResearch source}
Generally, once you submit your appeal the insurance company will indicate how long it takes to review and respond. If they deny your appeal, ask whether there is another level of appeal and what additional information that they require. You should exercise all of your appeals options until the insurance company either pays your bill or there are no other appeals options left.
Once you have exhausted all of your appeals, your last option is to file a lawsuit against the insurance company. There are two types of claims that people make against insurance providers. The first is for breach of contract where you try to prove that the company did not follow the terms of your policy. The second, and more difficult claim, is to file a lawsuit alleging that the insurance company acted in bad faith. A dispute or disagreement over coverage will not typically support a bad faith claim. If you intend to file a lawsuit, you should speak with an attorney.^{[16]XResearch source}
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Tips

Keep written records of all conversations, including the name or badge number of the person to whom you spoke, the date and the time you spoke as well as what agreement was reached.
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Send all correspondence "Certified Mail, Return Receipt Requested" in case you have to prove that you sent in your appeal by a certain date.
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