How to appeal an insurance claim or medical bill

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.

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.

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).

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.

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!

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.

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.

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.