Getting a bill for a medical procedure or an appointment you thought your insurance would cover can throw you for a loop. But if you think the bill was sent to you in error or you believe the amount listed is wrong, you can—and should—fight back. First, though, you need to know common mistakes to look for, as well as what your insurance plan does and does not cover.
Start by reviewing your insurer’s explanation of benefits. Was the service in network—that is, from providers that have typically agreed to reduced reimbursement from your insurance company? Next, call your insurer and ask the insurance representative to explain why the claim was denied (in part or in full), why certain services weren’t covered and what you need to do to fix it.
Denials of claims for in-network procedures are usually the easiest to resolve, says Katalin Goencz, a medical insurance and reimbursement specialist in Stamford, Conn. (Goencz also serves as the president of the nonprofit group Alliance of Claims Assistance Professionals.) If a provider sends incorrect information, it is required to resubmit corrected info directly to the insurance company once the provider has been alerted, she says. For example, an error in how a procedure was coded could lead to a denial, as could an outdated insurance card.
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In some cases, you could simply be billed erroneously. For example, the Coronavirus Aid, Relief and Economic Security (CARES) Act mandated that providers offer COVID-19 vaccines and boosters at no charge. Providers are prohibited from charging co-payments or administrative fees. However, you could receive a bill for a COVID-19 vaccination if the provider bills you directly instead of your insurer or due to human error in medical billing systems. If you’re charged for a vaccine, call your provider and dispute the charges. Your insurer may also be willing to help you get the bill waived.
Likewise, the Affordable Care Act requires your insurance to cover all of the costs of annual physical exams and other preventive care. However, if your doctor decides to order extra tests, such as an electro-cardiogram to track heart issues, your insurance company may conclude that the service isn’t a necessary part of your physical exam and send you a bill.
How to appeal
Most insurance companies allow you to file or appeal a claim online, which is useful because the system will usually flag missing or incorrect information. Goencz says some problems with out-of-network claims occur when a provider gives you a piece of paper to file with your insurance company but the paperwork has missing or incorrect information. If filing online isn’t an option, download and print out a paper claim form from the insurer’s website.
The No Surprises Act, which took effect in January, prohibits providers from charging patients out-of-network rates for emergency care and ancillary services, such as anesthesiology, for nonemergency procedures delivered by out-of-network providers at in-network facilities. The law also applies to out-of-network charges for air ambulances, which can cost thousands of dollars. If you receive an out-of-network charge for services covered by the legislation, file an appeal with your insurance company.
For nonemergency procedures, some out-of-network providers at in-network facilities can charge the higher rates if they give you an estimated bill at least 72 hours in advance and you agree to pay it. For procedures scheduled within that 72-hour window, you must be notified about the higher cost the day the appointment is made.
Finally, don’t let fears about your credit record deter you from challenging a medical bill. Debt collectors are required to wait 180 days from the time a medical bill becomes delinquent before reporting it to the three major credit bureaus. That provides extra time either for your insurance to pay the bill or, if it’s not covered, for you to work out a payment plan with the hospital or medical services billing department. In addition, if your insurance company pays a medical bill in full, the default account must be immediately removed from your credit report.
Avoid Surprise Medical Charges
Before you schedule a medical procedure, make sure you understand what is and isn’t covered by your insurance plan. Log on to your insurance company’s website and review your benefits, or call your insurance company and talk to a representative. Call the providers you plan to use to make sure they still accept your insurance. That’s important because a provider may have made recent changes that aren’t reflected on your insurance company’s website.
Ask the insurance representative about reimbursement rates for the procedure you need, or get an estimate from the online portal. Keep good records in the event you need to challenge a bill from your provider.
Goencz says one of her clients got an estimate from his insurance company for a colonoscopy, but when his claim was processed, it didn’t cover the entire cost. Because he had a record of the estimate, she says, “they paid up.”