A single stay in the hospital can result in a bewildering array of bills covering a number of services and providers. Some statements may provide scant details to justify charges while others could include descriptions or codes that make little sense to the average person.
“There’s a lot of needless complexity in our medical system,” says Marshall Allen, founder of the Allen Health Academy and author of “Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win.”
Unfortunately, the system isn’t likely to change anytime soon, and Allen encourages consumers to remain engaged and ask questions to confirm they are being billed correctly.
Billing mistakes could be the result of human error or even fraud, and knowing how to decipher a medical statement can be a money-saving skill. Before paying any medical bill, ask yourself the following questions:
— Do I need an itemized bill?
— Do I recognize all the charges?
— Are the dates, providers and procedure codes correct?
— Are there red flags indicating this is a medical billing scam?
— How old is the bill?
— Has my insurance been billed properly?
— Did I get billed for an out-of-network provider?
— Can I negotiate the balance?
— Do I need help disputing this bill?
Do I Need an Itemized Bill?
Some providers send bills that include the total due and little else. While more details probably aren’t needed if the bill is for a single office visit, complex procedures that come with an expensive price tag deserve a closer look.
Some providers are making it easy to get these details, and you may be able to log into an online account and review a digital bill. However, if you receive paper statements, you’ll need to call your provider to request itemization.
If a provider balks at the idea of sending an itemized bill, Allen suggests reminding them that HIPAA — the Health Insurance Portability and Accountability Act — guarantees patients access to information such as itemized bills. If necessary, send a letter to the billing department and cite the law in your request.
[READ: Should You Downsize to Save Money?]
Do I Recognize All the Charges?
Once you have an itemized bill, review everything listed to ensure it matches your records or recollection of the care you received. Don’t automatically assume that the information is correct. Bills are processed based on a coding system, and those codes are entered by hand, meaning there is always the chance of a worker hitting a wrong key.
“It’s going through too many hands, frankly,” says Howard Dvorkin, CPA and chairman of Debt.com. Multiple people may be involved in transcribing and processing visit notes, which leaves plenty of opportunity for mistakes to be made.
It could also be an insurance issue that causes a bill to look wrong.
“Patients need to be clear about whether the question is related to the health care provider’s bill or related to the payments made to the provider by the insurance company,” says Will Reilly, vice president of marketing for R1 RCM, a revenue cycle management company serving health care providers.
Contact your provider’s billing department with any questions. If you need to dispute a bill, contact your insurer as well. They may have staff who can assist in resolving billing issues.
Are the Dates, Providers and Procedure Codes Correct?
Beyond looking at the charges themselves, double-check the dates and providers listed. This can be especially important for hospital stays when bills might be generated every time a doctor stops by to check on your status. If you didn’t see a specialist on a particular day, you could be paying more than needed.
“If nobody questions it, they just get paid,” Dvorkin says.
You can take your review a step further by double-checking codes listed on the bill.
“It sounds complicated, but you can just Google the billing code and look at the description,” Allen says.
If the description doesn’t match the services rendered, dispute the bill. As an example, Allen notes that a level 5 charge for an emergency room visit is typically reserved for life and death situations such as multiple organ failure or a victim of a serious car accident.
“They shouldn’t be using a level 5 code because you had a cut on your knee,” Allen says.
Are There Red Flags Indicating This Is a Medical Billing Scam?
Most billing problems are the result of human error. However, you do need to watch for medical billing scams.
Some scammers might send bills that look legitimate but are for phony services. That’s one reason to carefully check dates and provider names.
Other red flags could be a billing address that doesn’t look familiar, requests for sensitive information such as a Social Security number or phone calls claiming to be from Medicare. Just as the IRS won’t call people, Medicare representatives typically don’t contact patients via the phone.
[READ: 10 Simple and Free Budgeting Tools.]
How Old Is the Bill?
It could take longer than you think for a medical bill to arrive in your mailbox. Many insurers require providers to bill them in a timely manner, but that could still be months. Once a bill is sent to the insurer, health care providers have to wait for payment before billing a patient for the balance.
While your bill winds through this process, it’s possible that your deductible has been met in the meantime. In that case, the insurance company will pay the entire amount. If you get an old bill, double-check the status of your deductible and, if it’s been met, ask your provider to rebill the insurer.
Has My Insurance Been Billed Properly?
If a bill is higher than expected, confirm that your insurer has been billed correctly. In addition to your bill, you should also get a separate statement from your insurance company for each bill they receive.
Compare your itemized statement to the explanation of benefits provided by your insurer to confirm they were billed for the same services. If a service is on your statement but does not appear on the EOB, contact your provider to request your insurer be billed.
The use of technology and online solutions can make this process easier for consumers, according to Reilly.
“With a digital approach, patients should be able to manage everything from a consolidated view,” he says. “This puts bills from hospitals, doctors and other clinicians in one place alongside the EOBs so patients can clearly see charges, insurance payments and out-of-pocket costs.”
Did I Get Billed for an Out-of-Network Provider?
Surprise billing, or balance billing, occurs when a patient believes they are getting care from an in-network provider, but the health care professional or facility is actually out of network. For instance, a person might be admitted to an in-network hospital, but a specialist providing services is not part of the network. As a result, an insurer may decline to cover some or all of their charges.
Many states have enacted laws regarding surprise billing, but their provisions vary widely. In January 2022, the federal No Surprises Act went into effect to provide consumers standardized protections nationwide.
Among the law’s provisions are bans on surprise bills for emergency services, out-of-network cost-sharing for emergency and some nonemergency services, and out-of-network charges for out-of-network providers who work in an in-network facility. Consumers who believe they have been incorrectly charged for these services can call the government’s No Surprises Help Desk at 1-800-985-3059 or file a complaint online.
However, the law doesn’t cover all situations. Allen recalls an experience of being billed an additional $200 for dental services despite being assured by the provider that they were in his insurance’s network. It wasn’t until Allen shared his plan to write an online review about the incident that he was refunded the $200 by the practice.
Can I Negotiate the Balance?
Don’t assume you have to pay the total listed on a bill. Health care providers often charge various amounts depending on whether you have insurance and which company provides coverage.
“When they bill you $3,000 and the providers get $300 from the insurance company, it’s ludicrous,” Dvorkin says.
Individual consumers might not have the same leverage as insurance companies, but people should know that billing amounts are not standardized and are not set in stone. “Every number in health care is negotiable,” Allen says.
Asking politely for a discount is usually the best way to begin negotiations. If that doesn’t work, and you feel as though you are not being charged fairly, using social media to leverage your concern can sometimes be effective, according to Allen.
Simply leaving a bill unpaid for a period of time can work too. Hospital collection rates are not great, particularly for emergency room visits, and providers may be happy to offer a discount in exchange for a cash payment.
Hospital bills of less than $500 cannot be reported to credit bureaus by law, Dvorkin notes. Larger bills cannot be reported until at least a year has passed.
It’s even better if you think to negotiate the price before an elective procedure since that’s when you have the most leverage to secure a reduced rate. If you do negotiate a bill — either before or after the procedure — be sure to get the agreement in writing.
[READ: Best Personal Finance Books.]
Do I Need Help Disputing This Bill?
The process of disputing a medical bill can be daunting, and if you feel overwhelmed, it may be best to ask for help.
“Hospitals are good at having people (available) to hold your hand,” according to Dvorkin. He says they may be able to clearly explain billing details, review statements for errors or direct you to assistance programs if you are having trouble with payments.
Hiring a patient advocate is another option, particularly if your bills are large and complex.
“If you have a massive snarl of a medical nightmare, a patient advocate can be worth their weight in gold,” Allen says.
You’ll have to pay for their services, though. If you can’t afford to hire one, some organizations, such as Allen’s business, are willing to help cover the cost if needed.
More from U.S. News
Ways to Live Green on a Budget
12 Shopping Tricks to Keep You Under Budget
9 Questions to Ask Before Paying Any Medical Bill originally appeared on usnews.com
Update 05/30/23: This story was previously published at an earlier date and has been updated with new information.
