How to appeal an insurance claim or medical bill
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 may even feel that you are being tortured. But you may find that you're right and can save a significant amount of money.
So despite doing all you could to find out your medical costs in advance, you still 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. 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.
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 may even feel that you are being tortured.
But you may find that you're right and can save a significant amount of money.
We'd like to hear how you do. Keep track of the process, and keep us informed at firstname.lastname@example.org.
Try to go into this without anger. Perhaps the people on the other end of the phone would like to help, but don't have the power to do so.
Being polite and even empathetic can be helpful. It will not necessarily help you in the early stages to argue with anger, impatience and a condescending attitude. Believe me, I've tried.
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.
Before you pick up the phone
Set up the filing system that works for you, whether it's electronic or paper.
In every call, in every case, take names, take notes, take phone numbers. Get as much in writing as you can.
Keep records of your calls and correspondence in chronological order in a file or in a spreadsheet.
Line up something else you can do while you're on hold, which might lessen your frustration.
Tell the representatives you talk to that you want email addresses. If they say they can only do U.S. mail and faxes, make sure they have a current mail and email address for you. Don't have a fax machine? Services like HelloFax let you handle sending and receiving digitally. Makes record-keeping easier, too.
If they say "We cannot give that to you because of HIPAA," the health insurance privacy law, ask for the specific part of the law that applies and say you will sign a waiver if necessary. These are your records, and you are entitled to them.
Get your insurance policy so you have a reference to verify what you are told.
Know the basics: Was the provider in-network or out of network? What does this procedure/prescription normally cost in your area? Use our Philly Health Costs data base to find out.
Step 1: Get the provider’s bill
Take your time reading through it, and comparing what you see with your experience. Among the kinds of questions you may find:
What was the diagnosis? (Read on to find out why this seemingly obvious fact is so critical.)
Why did you do what you did? The bill that was sent does not have CPT or HCPCS codes (these are coding systems that describe precisely what's in your record.)
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 (or surgeon or physician) 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 (or surgeon or physician).
Pro tip A: 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 B: Get the provider and the insurer talking as quickly as possible. Sometimes it's a simple misunderstanding. If you can get them on the phone together, maybe it can be resolved it quickly.
Step 2: Get the insurer’s record
This will often be part of your "explanation of benefits," or EOB, which, despite the name, explains very little. It's best to get authorization and a commitment of payment in advance.
See what was paid, what's your responsibility, and whether there were explanations listed.
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 and who to send it to.
Pro tip: Again, get your records both electronically and on paper (see above pro tip)
Pro tip: If you can get a single rep to be your point of contact, you will save time and trouble.
Step 2.5: If this is a work-based policy, get the employer involved
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, and the H.R. department might even step in to help you.
Step 3: Ask the provider questions
Some common issues we've seen:
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 insurer questions
Common issues we've seen:
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.
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.
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.
What if you’re still stuck?
Services called "medical billing advocates" or something similar may offer to help you. We don't know enough to recommend any of them, but if you choose this route, do your research and make sure you understand what their fees are.
If you are unable to make any progress with the insurer or the provider, you can appeal to the state insurance commissioner.
Try negotiating the price
Sometimes medical 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.
Please report your experience to us
Use our website to help yourself if your procedure is one that we track. 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.
Jeanne Pinder is founder and CEO of Clear Health Costs, the Inquirer's data partner in the Philly Health Costs project.