Even though Congress passed legislation, taking effect at the start of 2022, to address surprise outof- network medical expenses at in-network hospitals, there still are many ways that seemingly well-insured patients can be subjected to burdensome healthcare costs. Examples: Out-of-network doctor visits…ambulance rides, which are excluded from the legislation (though air ambulances are included)…and treatments the insurance company or Medicare deems not medically necessary or when patients are uninsured.
Here’s a six-step plan for what to do if you receive a massive medical bill—it’s often possible to pay much less…
1. Check the “Explanation of Benefits” (EOB) statement before paying.
This document details how much your coverage will pay and how much you must pay. It will be mailed to you by your insurer or Medicare and typically is marked “This Is Not a Bill.” When you receive it, compare the amount listed under “patient responsibility” or “you owe” with the amount the provider is billing you. These figures should match. If they don’t, call both the health-care provider’s billing office and the insurer/Medicare until you get an explanation for the discrepancy. Among the potential explanations: The care provider might have mailed your bill before your insurance/ Medicare paid its share…the provider might have submitted its claim incorrectly to your insurance/Medicare…or it might have failed to submit an insurance/Medicare claim at all. If necessary, make sure your health-care provider refiles the paperwork properly.
Also: Medical billing errors are very common. Read the bill and the EOB in search of procedures that do not seem relevant to your treatment—a coronary angioplasty if you were in the hospital for a hip replacement, for example—and contact the provider to question whether you actually received these services.
2. Ask your insurer/Medicare why a procedure was not well-covered.
Among the explanations your coverage provider might offer: The health-care provider wasn’t in network…the procedure wasn’t medically necessary…or the provider failed to submit the information required to process the claim. Don’t back down if you believe their explanations might be inaccurate—they often are. Examples: If you’re told the provider isn’t in network, you might say, “I confirmed that this provider is in network through your website—why is it being coded as out-of-network?” If you’re told the procedure wasn’t medically necessary, ask, “How does this need to be coded for you to cover it?” and/or ask your doctor to provide a written “letter of medical necessity” explaining why the procedure actually was necessary in your case. If you’re told the claim wasn’t submitted properly, contact the healthcare provider and ask for it to be resubmitted. Helpful: If you have Medicare, call 1-800-633-4227 to ask these questions…or visit Medicare.gov, click “Claims & Appeals” at the bottom left of the screen, then click “Go” under “Talk to Someone.”
3. File formal appeals with your coverage provider.
You have a legal right to submit at least two formal written appeals per medical bill with your insurer/ Medicare if you believe it is not covering a bill properly. A free template for these appeals is available at my organization’s website, PatientAdvocate.org (select “Order Free Publications” from the “Explore Our Resources” menu, then click “Engaging with Insurers: Appealing a Denial”). When you complete these appeals documents, keep in mind that you are essentially making a legal argument that the insurer/Medicare is failing to provide the coverage to which you are entitled, not an emotional argument that your bill is crushingly large. Approach this as you would any legal contract, using professional language.
4. Request financial assistance with hospital bills.
Ask the hospital’s billing department if you qualify for any financial assistance. Most hospitals have programs that can reduce or waive bills for people who can’t afford to pay. Eligibility rules vary, but even people with incomes above $100,000 may qualify when bills climb into five figures.
You can negotiate medical bills—if you can’t pay, the provider will have to sell your debt to a collection agency for pennies on the dollar, a result that the provider wants to avoid.
Strategy: Look up the typical cost paid for the procedures you received. Hospitals now are required to list their negotiated rates on their websites, or check HealthcareBlueBook.com (a membership site benefit provided by some employers) or Medicare.gov/ procedure-price-lookup. Compare the prices you find to your bill. Even if you’re not going through a hospital system, you still can use your local hospital’s list to get an idea of a reasonable charge. Generally, a hospital charge will be more than an in-office service at an independent provider.
Next, call the provider’s billing office. Explain that you can’t afford to pay the amount billed, then use the lowest price you uncovered for the procedures— that’s usually the Medicare price—as the starting point for negotiations. If you can afford to pay immediately, ask if the provider offers prompt-payment discounts or cash discounts.If you can’t afford to pay in a lump sum, ask the provider for a payment plan that fits your budget after you have negotiated a price. Whatever terms you negotiate, get the agreement in writing before making any payment. This written agreement should confirm that the amount you are paying will be considered payment in full…and, if possible, that your failure to pay the entire amount originally billed will not be listed as a late or unpaid debt on your credit reports.
6. Enlist outside help.
There are nonprofit organizations that help people find financial assistance or other means of support, such as negotiating a lowered rate. Locate organizations that might help you on PatientAdvocate.org (select the “National Financial Resource Directory” button under the “Explore Our Resource” tab). Also ask any religious and fraternal organizations you belong to whether they have programs that could help. Your town or county might have programs that provide assistance to residents facing financial challenges as well.
Helpful: If you have a chronic, lifethreatening and/or debilitating disease, the Patient Advocate Foundation might be able to provide access to a case manager who can review your bills for errors, help you locate financial assistance and negotiate bills on your behalf. We’ve helped patients with cancer, HIV/AIDs, lupus and diabetes. (You must be receiving care or have received care within the US, and we don’t handle behavioral/ mental health, accidents or pregnancy.). If you don’t qualify for this assistance, you can engage a for-profit medical billing advocate who can vet and negotiate bills on your behalf for a fee—potentially $50 to $100 or more an hour…or 25% to 35% of the amount the advocate gets your medical bills reduced.
Also contact area newspaper and TV reporters who cover consumer advocacy and/or health-care issues. If a reporter starts poking into your case, there’s a good chance that the provider or insurer may back down and offer better terms to avoid negative publicity. Reporters can’t cover everyone who has huge medical bills, however, so when you reach out to them, stress the ways in which your bills are especially egregious and/or your situation especially heart- wrenching.