12 steps for appealing a bill or claim: Part 2 of our billing series

(Updated 2023) Appealing a bill or claim is not fun. But you have a huge bill, and you’re sure there’s been a mistake, either in the bill or the insurer’s processing of a claim. What now?

Here’s a step-by-step course of action. We cannot guarantee that you will win, but at least you will have tried. Read first, and then dive in! And if you want us to help, let us know. Sometimes we can, though arguing bills is not our core business — we love to tell people how to avoid bad bills on the front end if they can. This is Part 2 of a series: You may also be interested in Part 1, “How to find out what stuff costs in advance.”

O.K., steel yourself. This is not likely to be fun, and you’re probably going to spend a fair amount of time on hold, in phone voice prompt systems, being asked to find a fax machine and so on. You will most likely feel that you are being tortured.

But! You might find that the bills are in error, or you don’t need to pay, or you can pay less than the bill, or something similar.

We are here to help, and also happy to hear your stories. So keep track, and keep us informed at info (at) clearhealthcosts (dot) com.

Preliminary steps to consider

Try to go into this without being angry. Perhaps the people on the other end of the phone would like to help, but they may not be able to because of office or corporate rules or whatever.

Being polite is helpful: You will catch more flies with honey than with vinegar. We all know how upset and annoyed you are — but it will not necessarily help you in the early stages to argue a bill or coverage with anger, impatience and condescending attitude. Believe me, I’ve tried.

Also, it’s not impossible that the person on the other end of the phone has experienced this as well. You might do those journalist things — try being empathetic, and try asking a question and then leaving a (sometimes uncomfortable) silence while you wait for an answer.

Assess your tolerance for time spent vs. material gain. I have argued a $5 bill before because it offended me, but not everyone feels that way. Sometimes your time is more valuable than the $5. Only you can make that judgment.

Medical billing is complicated and counterintuitive. Here’s a post about that.

Medical bills are hard to read. Here’s a post about that.

The ‘No Surprises Act’ for medical bills

A federal law called the “No Surprises Act” went into effect Jan. 1, 2022. It protects consumers from being charged out-of-network rates in three situations:

Emergency services at a hospital emergency department or a free-standing emergency department
Some non-emergency out-of-network services in an in-network hospital or surgery center (for example, if an out-of-network doctor assists in a scheduled surgery
Air ambulances (but not ground ambulances)

Clearly this does not encompass all the potential surprise medical billing possibilities. But if you got a surprise bill in these circumstances, before you do anything, you should see if the N.S.A. will give you relief. How do you do that? The Centers for Medicare & Medicaid Services has a new help desk and hotline. Also, many states have a consumer assistance program, or several programs. Here’s a helpful CMS map with resources for those programs.

Get a filing system going

We hope that before the event or procedure you asked “How much will this cost? How much will it cost me? What if I paid cash?” Our handbook about that is Part I of this series. Find it here.

If you didn’t ask what it will cost on the front end, you can use our tools to figure out generally what others are paying/have paid, per the suggestions in that blog post.

In every call, in every case, take names, take notes, take phone numbers. Get as much in writing as you can.

Tell the representatives you talk to that you want email addresses. If they say they can only do mail and faxes, make sure they have a current mail and email address for you. If you need to get and give faxes, try one of the services like HelloFax etc.

Put things in chronological order for yourself in a file or in a spreadsheet. Make your filing system work for you: Paper? Sure. Electronic is better for you? Go for it. Just keep records, and keep them well.

This may require multiple phone calls, spending a lot of time on hold, getting people on the same line (insurer rep and provider rep). This is where it’s handy to work from home, where you can be on hold and actually accomplishing other things while you wait.

If they say “We cannot give that to you because of HIPAA,” the health insurance privacy law, ask them to tell you the specific part of the law that applies, and, if necessary, that you will sign a waiver. In many cases, HIPAA is used these days as an obstacle, not what it was intended to be — a guarantee of privacy protection for people with AIDS.

These are your records, and you are entitled to them. Take notes, take names, take numbers. And keep asking.

A large number of bills have mistakes in them – some people say as many as 80 percent of hospital bills, for example – so it’s well worth your while to examine what was diagnosed, ordered, prescribed and actually done.

Get your insurance policy so you have a reference.

Know the basics: were you in network or out of network? What’s this procedure/prescription normally cost in your area? Again, here’s a blog post that will let you get at some of this — the link to the first part in our series.

Step 1: Get the provider’s bill.

You may be starting to ask a provider what they did, and an insurer why they did not cover it. This is a common scenario, and one that is fraught with lengthy stays on a voicemail prompt phone tree.

What was the diagnosis?

Why did you do what you did? The bill that was sent does not have CPT or HCPCS codes. (The coding system is notoriously complicated, but you’ll need to have at least a passing familiarity with the system, which uses various medical codes to identify different procedures. More here.)

It says here that there was surgery on the left shoulder, but my left shoulder was fine — the problem was in my right shoulder, and that’s where the stitches are.

Why am I being billed for all of these things: anesthesia, general anesthesia, an anesthesiologist’s services, and the actual anesthesia, plus the anti-nausea medication for anesthesia?

I had another anesthesia experience 6 months ago, and the billed price was one-third of what is billed here. Can you explain?

Was the anesthesiologist in network? This was an in-network provider and an in-network hospital/surgical center. I asked in advance to be sure there was an in-network anesthesiologist.

Was the surgeon/provider in network? This was an in-network hospital/surgical center. I asked in advance to be sure there was an in-network surgeon/provider.

Take names, take notes, take phone numbers. Instruct the representative to put information about your objections in your record so you don’t have to repeat everything every time.

While you’re doing this, you might want to collect other records: Diagnosis from the doctor, etc. You will see later how this might be useful.

Tell them you want to question the bill and/or insurance claim in writing, and ask how to do that — who to send it to, etc. More on this later, to protect you from a flawed bill going to collections.

Pro tip: Some providers will give you an opportunity to get your bill electronically — via email. If you do, elect to also receive records on paper. This will be a good paper trail, which you cannot mimic with electronic records.

Pro tip: Get the provider and the insurer talking as quickly as possible. Sometimes it’s a simple and easy misunderstanding. If you can get them on the phone together, maybe you can resolve it quickly.

Step 2: Get the insurer’s record.

This will quite often be part of your “explanation of benefits,” which, of course, explains very little. It’s best to get authorization and a commitment of payment in advance.

See what was paid, what’s your responsibility, were there explanations on the bill?

Take names, take notes, take phone numbers.

Instruct the representative to put information about your objections in your record so you don’t have to repeat everything every time.

Pro tip: Some insurers will give you an opportunity to get your explanation of benefits electronically — via email. If you do, elect to also receive records on paper. This will be a good paper trail, which you cannot mimic with electronic records.

Pro tip: If you can get a single rep to be your point of contact, you will save time and trouble. Some places they will do this only after a certain point; some places they insist that the record is in your account. But in my experience, even if the record is there, you’re still explaining things over and over again. Get a single rep if you can.

Pro tip: A member of our community added on Facebook: “If it’s a procedure or full treatment that has been denied, ask for the qualifications of those on the committee that has rejected it. It could be just those out of high school with NO medical education.”

Step 2.5: If this is an employer policy, get the employer involved.

We have heard of numerous occasions when a representative of the human resources department can fix these problems. The employer is essentially the customer of the insurer; if the insurer’s denying a claim, that’s quite possibly something the employer would want to know about — on the ground that the employer is paying for claims to be paid, and not denied.

If it’s an employer policy, make sure this base is touched at every stage.

Step 3: Ask the provider questions.

I got a bill I don’t understand.

Why did you charge me for this?

What is this thing? Please explain. When you say “anesthesia,” what is the CPT code for it?

My research suggests that this price is ridiculous!

I had a surgical experience once in which I was charged $1,419 for a drug named Ondansetron in a size called 4MG 2ML, which I later found I could buy for $2.49. I used these facts to argue with the provider about the bill they sent me after the insurance company paid. I wrote this blog post about it as I was thinking about founding ClearHealthCosts.

Step 4: Ask the insurance company questions and follow the appeal process.

Why did you refuse to pay for this charge?

I called before, and your rep said it was covered. Why are you not paying? Can you please check again?

Can you tell me where in my policy it explains that?

My records don’t agree with yours.

Know your plan. If there’s a reason the insurer says “We don’t pay for that,” find out what it is, and get the rep to point you to the specific language.

The explanation of benefits will have an appeal process; follow it.

Sometimes an incorrect HCPCS code can cause a bill to be rejected; sometimes there’s confusion behind the scenes between the provider and the insurance company. If you ask questions, you may get answers.

There’s a lot of information out there about what’s supposed to happen and how. For example, here’s a crazy detailed explanation about what is accepted or allowed or expected in a hernia repair. You probably don’t need to get this far in the weeds, but you should know that Google can be your friend in a bill appeal.

Now, with all the information you’ve collected, you’re in a position to make an informed appeal. Do it in writing. Send to everybody you’ve talked to, and also to the CEO of the provider and the insurer. Yes, to the CEO. And tell them you expect them to rectify the problem in 30 days.

Many times a bill from a provider and an insurance company’s explanation of benefits tell the procedure for an appeal. Follow that procedure: Where to send it, within what timeframe and so on. This is supposed to stop the clock on bill collections and keep a flawed bill from damaging your credit. If all you have is phone calls of complaint, you won’t have that written record.

Repeating this, because it’s important: Get the provider and the insurer talking as quickly as possible. Sometimes it’s a simple and easy misunderstanding.

Pro tip: Ask for the claim history. This is different from an appeal. This is the background information the company uses to assess a claim, our friends at ProPublica advise. “When a health insurance company denies your claim, it creates a file that can include all the notes, phone call audio and other correspondence involved in deciding whether to approve or deny your claim,” they Tweeted. ProPublica has written articles about people with claim files, including one man who got recordings of executives making fun of his claims. Another patient found out how much the insurer thought it would save by denying his claim: “Changing it, a Cigna employee estimated, could save more than $98,000.” Obviously, this could be helpful in overturning a denial. Their post has detailed information about how to ask for the claim history.

Step 4.5: If this is an employer policy, keep the employer involved.

This may be your best shot at fixing it. Don’t leave them out of the loop.

Step 5. Hope you’re not a strange or unusual case.

You would be amazed at how these bills get tangled up and denied.

One friend got a bill for $2,500 or so for a routine physical. She thought it should be covered, but guessed she was in error. Before paying the bill, she called the provider and asked about the bill; the representative said “Oh, no, you don’t have to pay that.” Why did she get the bill? “A mistake.” This happens more often than you could possibly imagine.

Here’s a series written by my friend Mandi Bishop about how a hip injury was put into a doctor’s record as a shoulder injury, and the treatments were denied. This is a model of how to make an appeal of an insurance denial; most of us do not have the resources or the knowledge to do this, but it’s a good way to think about documenting and being very clear. This is where finding the diagnosis is important in overturning a denial. This case involved $60,000 in denied claims.

I had a strange experience once: I was on insurance from my former employer, The New York Times, after a buyout, and then transitioned to Cobra. Providers kept insisting on billing me for my deductible responsibility, though I knew I’d met it. The insurer, the third-party benefits manager and the human resources people at The Times all agreed I wasn’t responsible, but the bills kept coming, from several providers over the course of months.

Eventually a person at the third-party benefits manager figured it out: The policy identified me by my Employee ID Number while I was at The Times, but when I left, the policy identified me by my Social Security number. The computer system decided I was two separate people, with two separate deductible responsibilities. And so it goes.

What you’re asked to pay: Health care bills are seldom paid by the insurer at the full sticker price. Often the insurer has a contract agreeing that it will pay a “negotiated rate” or “allowed rate” or “contract rate” for a given service to a given provider. That may be written on your bill, along with a notation that your responsibility is $0.

But sometimes, the difference between the sticker price and the insurer’s payment is your responsibility, depending on how your plan’s written, whether you’ve met your deductible, whether you have co-insurance, and so on. (Co-insurance is when you have to pay a percentage of a bill — say 10 percent or 20 percent of either the billed rate or the negotiated rate.)

To make matters more complicated, there is a practice in health care called “balance billing” — that is, when the bill from the provider is covered only partially by the insurer, and the insurer bills you for the balance. This kind of bill may be legal in your state or illegal; it may be allowable under your insurance policy or not allowable. Knowing what’s going on with your bill will be crucial to knowing if you have to pay.

New federal protections against surprise and balance billing are scheduled to come into effect in 2022. Read more here.

Here’s an explanation of balance billing, with some state-by-state regulatory information. If you knew it was an out-of-network provider or did not know, the rules are different. It’s slightly dated.

This more current state-by-state breakdown from the Commonwealth Fund will tell you what applies in your state.

Sometimes what looks like illegal balance billing is actually something that, under contract, you are responsible for, but since the language in your document is so convoluted and since the prices is so high, you have a hard time believing it’s your responsibility. Here’s a blog post about that, relating to a huge bill sent to a Seattle area man after emergency gall bladder surgery — though he thought his employer-sponsored insurance would protect him from such a hefty bill.

This is insanely complicated, partly because it’s governed not only by federal laws and state laws, but also by common practices among providers. This is made more chaotic by the current rage for mergers and acquisitions, meaning a provider that billed one way yesterday and was part of one network may change its rules overnight.

It’s also an area strewn with mistake upon mistake.

Step 6. Call everyone again.

Make a pile of paper with documentation. Send it to everybody on the list. Tell them specifically that you want them to rectify the problem in 30 days. And follow up.

Here’s a blog post about a woman who made one phone call and got the problem solved. May this happen to you!

If it doesn’t, keep at it.

Step 7. What to do if you’re still stuck.

There are services that will offer to do this for you. Quite often they are called “medical billing advocates” or something similar.

Some will work on contingency, for example, “if we knock $3,000 off your bill, we’ll keep a third.” Others work on a subscription basis. Some won’t charge you unless they can reduce your bill. This is an area that is constantly changing. Do your research before committing to anything.

People with a serious medical condition may qualify for assistance from the Patient Advocate Foundation, a nonprofit that does various kinds of advocacy.

If you are unable to make any progress with the insurer or the provider, you can appeal to the state insurance commissioner.

Here’s a blog post about a man who got a bill reduced by a lot. He thinks it was because he went to the hospital and talked to people, and that does make sense: It’s probably easier for a billing office person to dismiss you when you’re on the phone, and harder when you’re in the office with her.

Here’s a blog post about a woman who argued a bill and saved $155.12.

Hire a lawyer? Maybe. Here’s a Kaiser Health News article about lawyers, contract law and other avenues of appeal.

Step 8. We hear that sometimes you can offer to pay a lower price.

Often these bills are charged on a “chargemaster price” — essentially similar to a “sticker price” or “manufacturer’s suggested retail price” — which can be wildly inflated. (Here’s our explainer about how the billing system works again.)

We frequently hear that providers will accept a lower rate if you offer to pay immediately. We have also heard that providers will put you on a payment plan, with a monthly payment of modest size. There are no hard and fast rules about this.

We also have heard people suggest that you wait to make this offer until a bill has been sent to a collections agency. We do not recommend that.

Step 9. Financial aid, from the hospital, doctor or government.

Increasingly we hear of people getting financial aid. This can come from the hospital, the doctor, from the state or from some other source.

One of the first things you should check: The hospital should have a “charity care” or financial aid policy. They are required to post this online under the Affordable Care Act; no such rules apply to doctors, though.

That policy often requires you to apply, with supporting documents like tax returns or paystubs, and it is generally tested on several issues: How big is your household and what is your income.

The stipulations on this can be fairly generous, say up to 400 percent of the federal poverty level. Policies vary from state to state, and differ for nonprofits and for-profits. Nonprofits are required to provide more charity care, and there are a lot of nonprofit hospitals in the U.S.

You can learn more about the process in this interview we did with Jared Walker at DollarFor.org, which will help you find if you qualify and will help you apply. Find DollarFor here.

A lot of people don’t think they qualify for “charity care,” but the income levels are quite generous. One expert told us that as many as 80 percent of people in the U.S. qualify with household earnings under 400 percent of the federal poverty level.

This tends to be time-consuming, and is not a certainty. Another expert told us that even if people might qualify, they are often reluctant to supply all the documentation required to achieve the charity care designation.

Also it can be easier to talk about price before: If you can, try to establish a price you know about and can afford before, rather than after.

These programs vary greatly from institution to institution and state by state. Here’s a great explainer from U.S. News and World Report.

Here’s a blog post about a woman who was diagnosed with breast cancer while she was uninsured, and essentially sought financial help before getting treatment.

Here’s a blog post about a woman who had a terrible run of bad fortune while uninsured, and how she dealt with the various financial aid options.

Red flag: Make sure you see the words “charity care.” When you are looking for “financial aid” on a hospital’s web site, some places will try to direct you to “financing,” which might be an application promising interest-free or low-interest credit. This can be tricky. The financing application is basically an application for consumer credit, and it might have similar terms and conditions to credit card debt – hefty interest and penalties, for example, and it will be treated as consumer debt rather than as medical debt, which is not as damaging to your credit.

Step 10. Social media, change.org and so on.

We have heard of people who went to Twitter and got a claim overturned, as in this case, when a massive social media campaign caused Aetna to reverse a decision denying payment for treatment to a colon cancer patient.

We have heard of people who went to other sources. My friend Amy Gleason, for example, generated a petition on change.org that caused Blue Cross to overturn a decision about her daughters’ care. She tells the story in a blog post here.

(Update: A close look at charity options, crowdfunding and the like can be found here in a roundup by Helaine Olen at The Atlantic. That piece and this one, in Slate by Jordan Weissman, more specifically on crowdfunding, point out that many crowdfunding campaigns do not reach their goals.)

Step 11: Ah yes, Medicare.

If it’s Medicare, try the State Health Insurance hotline. Some are better than others; here in the New York City area, the one in Manhattan is amazing, while some in the New York City suburbs are less so.

Step 12: The long game.

Sometimes it takes a year or so for these things to shake out: A year in which you try to fix it and the hospital and insurer yell at each other and try to scare the pants off of you. I have counseled others: Get your paperwork and your official challenges in order (see above) and then know that it takes some time. Tell yourself you’ll take 10 minutes a day to worry about this, and then put it on the back shelf.

This is by no means me saying “It’s OK for them to do this to you,” but rather me saying … sometimes it takes a while. And indeed, this is an incredible amount of work and emotional labor for you to go through. Imagine the thousands of people going through this every day, and ask yourself if there isn’t a better way.

Resources

Debt collection, if it comes to that, is a complicated business. We told you before to get your appeal in writing, to follow the insurer’s or the hospital’s procedures (we know how time-consuming that is, but if you don’t do it, you might wind up in collections or in court).

Here are some resources.

Know your rights. State laws are very different: Some states have laws protecting your primary home, your car and even your livestock from collection activities; some protect your bank account, your paycheck or your child support. This National Consumer Law Center report shows state-by-state protections for what can and cannot be confiscated by a debt collector..
Scare tactics are not uncommon; don’t give in. Collection activities are governed by the federal Fair Debt Collection Practices Act – what debt collectors can do and how. They can’t call you in the middle of the night, or threaten to go to your employer and describe you as a deadbeat.
It’s up to you to guard your credit: The federal Fair Credit Reporting Act covers how debt collection is reported in credit reports. If a creditor is putting multiple negative reports on your record, they may be breaking or bending the law. A bad credit report may mean that you’ll pay more for your mortgage, your credit card and your car loan.
Did you get sued for an overdue debt? Don’t ignore the legal paperwork. If you ignore it, chances are it will only get worse. Put your challenge in writing. Show up in court if need be.
A new federal law also is designed to protect people against surprise medical bills. The U.S. Public Interest Research Group wrote this: Surprise Billing Patient Protections
Need more details? The National Consumer Law Center collects Consumer Debt Advice (includes articles about medical debt). The Consumer Finance Protection Bureau has these consumer tools on debt protection.
Need help? A number of organizations can help people with medical and other bills in collection. They may be state or local organizations. In New York City, the Community Service Society of New York will help you argue a bill. In Texas, and other states, the Legal Aid folks may be your best bet: Texas Rio Grande Legal Aid or Lone Star Legal Aid. Legal Aid Society of Cleveland is another, or Legal Services of Alabama. A list of resources collected by the Consumer Finance Protection Bureau is here.
The Consumer Finance Protection Bureau accepts complaints and queries the companies that are named. You can complain in their online form or by phone at (855) 411-2372. The process is described on this page.

Finally, use our info and report back

Use our website to help yourself.

Use the search box on top of the page to find prices. The Medicare reimbursement rate for your procedure in your area is what Medicare pays providers; it’s the closest thing to a fixed or benchmark price in the marketplace.

Go to our blog page and search for your procedure. You’re likely to find information about what others have paid for a colonoscopy, a gall bladder removal, a sleep study, a blood test.

Check out our “useful links” page.

Google around: You might find someone in a similar position.

When you’ve finished the process, let us know what happened.

Part 1: How much will that cost/did that cost.

Part 3: How to appeal a denial.

Negotiating a bill.

Save money by paying cash for healthcare, even if you’re insured

How to save on prescriptions.

Maybe it’s better to put away your insurance card and pay cash.