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.
Take your time reading through it, and comparing what you see with your experience. Among the kinds of questions you may find:
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.
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.
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.
Some common issues we've seen:
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.
Common issues we've seen:
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.
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.