Just because you get a medical bill doesn’t mean you have to pay it.
If you got a restaurant tab that was $50 more than you expected, you’d double check that receipt for every appetizer and dessert, right? You should do the same for your medical bills.
But before you start celebrating, there’s a catch: Proving you don’t owe will require work. That doesn’t mean it isn’t worth the effort, and it could definitely be worth the money.
Among those with employer health coverage, 10.3 million Americans spent 10% or more (or 5% or more if they have lower incomes) of their gross income on out-of-pocket costs — excluding premiums — according to a Commonwealth Fund report. And those are the people with insurance.
Contributing to that amount are the people who pay the official-looking bills from providers without question.
And here’s the thing, medical billing errors — and fraud — are extremely prevalent. As many as 80% of hospital bills have errors, so checking your medical bills can be the first line of defense against mistakes as well as illegal medical billing practices.
And that vigilance goes for older medical debt, too.
But how can you decipher the jargon and determine if there is an error on your bill? This step-by-step guide to correcting medical billing errors will help you decide what you actually owe and when to pay it.
How to Correct Medical Billing Errors
There are ways to save money on medical bills before you ever get them. But those preventative measures can only take you so far, and once you get the bill (or bills), it can be just as overwhelming and confusing as the trip to the emergency room.
Before giving up and paying the bill — or worse, ignoring it and letting it go to collections — check out our guide on how to correct medical billing errors.
1. Organize, Organize, Organize
Medical billing involves a lot of paperwork, so staying organized and retaining every piece of evidence pertinent to your bill is key.
That organization should start before you even receive a bill, according to Tracy McDougald, advocate manager for CoPatient, a company that negotiates discounts and finds errors in medical bills for its customers.
“You should know what your deductible is and whether or not it has been met,” she said. “Those are the things you can check on in preparation for this bill.”
The first letter you should receive from your provider is an itemization of services to identify what they’re billing your insurance for.
“It doesn’t mean you have to pay it, it just means this is for your information,” McDougald said. “You want to hold onto that.”
The next delivery will be the Explanation of Benefits (EOB) from your insurance provider. You can recognize this letter by the phrase “THIS IS NOT A BILL” printed in large type.
Sign up with your insurance company for electronic alerts when your Explanation of Benefits is available so you can start your review process before the document arrives in the mail.
The letter is correct: It’s not a bill. But it is a vital piece of information that you can use to compare with the itemized bill and to start questioning the charges, according to Craig Antico, co-founder of the national charity RIP Medical Debt.
“You’re going to be able to match the EOB to this bill that you just got in the mail,” he said. “See if it’s right — does it make any sense? It’s going to have little codes on it saying why [the insurance company] didn’t pay — does that make any sense? Is this an out-of-network provider?”
McDougald agreed that you should start working on the comparison right away, ensuring that the services listed in the itemized bill are the ones being covered in your Explanation of Benefits. Look for a phrase like “patient payment” or “patient’s responsibility” on your EOB to determine how much your insurance company says you owe your provider.
When you receive the final bill from your provider, the amount due should be the same as what was listed on your Explanation of Benefits.
2. Research and Compare Your Charges
Now it’s time for some detective work.
Comparing bills starts with understanding what your insurance did or didn’t cover, according to McDougald.
“Maybe your insurance didn’t pay as much as they’re supposed to,” she said. “[If] your statement of benefits says they paid 80% of what you’re allowed for an emergency room visit, you want to make sure your balance is the 20%.
“If it’s not, you need to find out if it went to deductible, if there was a non-covered service.”
That means understanding your health insurance coverage, whether it’s re-reading the plan, asking your employer’s benefits department about your coverage or calling your insurance company to ask them to explain the difference.
Current Procedural Terminology (CPT) codes are universal codes used by health care providers and insurance companies to classify procedures and services for medical claim billing.
Once you’ve determined your coverage, it’s time to look at the itemized bill to decide if what you’re getting billed for is what you actually received. McDougald’s advice: “Question everything that just doesn’t look right to you.”
She provided the following examples of common billing errors to watch out for, some of which are illegal medical billing practices.
This is typically a human error — if letters are transposed or numbers are a digit off, you could receive a bill for thousands of dollars for surgery on a broken bone when you only had a slight fracture that was wrapped in the office.
Yes, it can be confusing, but there are resources to help you understand what the codes mean, according to McDougald.
“If you see a CPT code, you can go to Healthcare Bluebook — it is really good at giving you explanations,” she said. “They can also provide pricing for your general vicinity where you live, so you can see the high and low.
“Or you can Google the CPT code and you’ll probably find a description of the service.”
This is when a provider charges for a higher level of service or equipment than was provided. It can still be the result of human error, but it is a type of medical billing fraud, McDougald explained.
“For example, with a new patient visit… it would be given a level of care — it could be minimal or it could be extended or complex,” she said. “If you don’t feel [the level listed] is appropriate, that’s when you start questioning what they’re billing and why they feel their services warranted that level of care.”
Bundling is designed to group services for a procedure under a single code so that a provider receives a single payment.
Unbundling is when a provider tries to charge for the coded procedure as separate services. It can also be when the provider bills you for the coded procedure but also bills you for the individual services — like charging you for your hospital room when it should be included in the surgical procedure bundled code.
Discovering unbundling practices can sometimes be tricky, according to McDougald, but you should ask that the itemized bill be clear enough for you to at least raise questions if a cost seems abnormally high.
“If it just says, ‘supplies,’ and there’s a dollar amount, that’s not specific enough — that’s not an itemized bill,” she said. “They need to explain to you exactly what is in that charge for supplies. And that’s when you say, ‘Well, isn’t that part of my surgical procedure?’”
If you’re unsure of what’s included in a bundled service, you can also ask your insurance company for assistance, since it’s in their best interest to discover providers who are overcharging through this illegal billing practice.
3. Call Your Provider
If you suspect there is a billing error, it’s time to call the hospital billing department or your provider’s office manager.
Remain calm and professional when questioning the error — remember, people entering codes are human, so mistakes do happen. However, you should not be afraid to request immediate action, as well as any documentation that can help your case, McDougald emphasized.
“If I found anything on the bill that didn’t look right, I would call them and say, ‘I’m disputing my bill — I want you to put a hold on my account,’” she said. “If you need paperwork, ask for it at that time so you can complete your own review.”
To help you understand what services and equipment were used during your visits, you can request your medical records to compare what the doctor says you received vs. what the bill says you received.
If you spot a discrepancy, stand firm about what you know is accurate instead of deferring to the provider if it claims that the billing is standard operating procedure.
“You have to be tough with them — you can’t just say, ‘Oh, I don’t think this is right,’” McDougald said. “You have to tell them, ‘This is not what happened [or] you did not use this on me. Show me proof in my medical records that you used it on me.’”
“Don’t let them say, ‘This is just what we do.’ That’s not a good enough answer.”
Even if the medical bill you’re calling about is an older debt, you can still request your medical records to dispute a charge if you suspect there’s an error.
“If you’re running into problems, then you can always approach your primary care physician and ask them if they could request the records or pull a copy of your records for you,” McDougald said.
If the provider agrees there is an error, request that it send you a new bill with the corrected amount that’s due.
4. Escalate if Necessary or Seek Outside Help
If your provider refuses to budge on the bill and you suspect it isn’t legit, there are additional options for disputing your medical bill.
First, call your insurance company’s anti-fraud department, which can help you dispute charges. (The phone number should appear on your Explanation of Benefits.)
Don’t let them say, ‘This is just what we do.’ That’s not a good enough answer.
If you aren’t getting anywhere with your insurance company, you can file a complaint on your own with your state’s department of insurance — find the form for your state here.
And if the process is becoming too much for you to handle, consider seeking outside assistance from a patient advocate or attorney.
Medical billing errors can sometimes mean a difference of thousands of dollars in medical bills — consider it worth your time to ask questions.
Tiffany Wendeln Connors is a staff writer/editor at The Penny Hoarder. Read her bio and other work here, then catch her on Twitter @TiffanyWendeln.