10 steps for appealing a medical claim or bill
Jeanne Pinder is the founder and CEO of ClearHealthCosts. Previously she worked for The New York Times for 23 years as an editor, reporter and human resources executive. This article originally appeared on ClearHealthCosts.com.
So you got a huge bill, and you're sure there's been a mistake, either in the bill or the insurer's processing of a claim. You want to appeal, because it's a lot of money. 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.
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@clearhealthcosts.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.
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 1 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.
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.
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.
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.
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.
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.
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.
Pro tip: 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.
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.
Here's an explanation of balance billing from 2015, 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.
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.
For more detail, the Robert Wood Johnson Foundation report can be useful; find it here.
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.
We do not know much about these providers. A few things we do know: Some will work on contingency, for example, "if we knock $3,000 off your bill, we'll keep half." Others work on a subscription basis. We do not know or recommend any of them; this is an area that is constantly changing. We can only suggest: Do your research before committing to anything.
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.
(Update: 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.
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 provider or government
Occasionally we hear of people going on financial aid. This can come from the hospital/provider, from the state or from some other source. This tends to be time-consuming, and is not a certainty. Also it's easier to talk about price before: If you can, establish a price you know about and can afford before, rather than after.
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.
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.
(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.)
Finally, use our info and report back
Use the ClearHealthCosts 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 the ClearHealthCosts 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 the ClearHealthCosts "useful links" page.
Google around: You might find someone in a similar position.
When you've finished the process, let us know what happened. Email: info@clearhealthcosts.com.
