Following our series The Price We Pay, WFAE has partnered with Jeanne Pinder, CEO and founder of the media company Clear Health Costs, on a series of columns to help readers find ways to navigate their own health care costs.
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 it's worth trying.
OK, steel yourself. 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 by putting in this effort, you might find that the bills, in fact, are in error or that you don't need to pay or can pay less than the bill, or some similar positive outcome.
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. As they say, 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 or a 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. 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.
Medical billing is complicated and counterintuitive. The figures may seem incomprehensible, and it may often seem like the hospital and the insurer are arguing about something you don't understand. Here'sa post about that.
Medical bills are hard to read. Here'sa post about that.
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 advice about that is in Part 1of this series.
If you didn't ask what it will cost on the front end, you can use our recommendations in Part 1 to figure out generally what others are paying/have paid.
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 mailing and email address for you. If you need to receiveand send faxes but you don't have a fax machine, there are online fax services that you can use. A quick internet search will give you several options.
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 together (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, which is not what it was intended to be. The law was designed to protect patient health information from being shared without the patient's consent. Since you are the patient, it should not prevent you from receiving information about your medical care and billing.
These are your records, and you are entitled to them. So make sure to take notes, take names, take numbers. And keep asking.
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
A large number of bills have mistakes in them – some people sayas many as 80% of hospital bills, for example – so it’s well worth your while to examine what was diagnosed, ordered, prescribed and actually done. You may start by asking 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.
Review the bill for the bill for the following things and be prepared to ask these questions:
What was the diagnosis?
Why did you do what you did? The bill that was sent does not have CPT or HCPCS codes. (The coding system is notoriously complicated, but you'll need to have at least a passing familiarity with the system, which uses various medical codes to identify different procedures. Morehere.)
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, the actual anesthesia, plus the anti-nausea medication for anesthesia?
I had a previousanesthesia experience, 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.
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. More on this later to protect yourself from a flawed bill going to collections.
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.
And remember to always take names, take notes, take phone numbers.
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?
As with the biller, instruct the representative to put your objections in the record, and 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.
Some insurers will give you an opportunity to get your explanation of benefits electronically — via email. If it works better for you, elect to also receive records on paper. This will be a good paper trail, which you sometimes cannot mimic as well with electronic records.
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 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. Having a single rep helps you avoid that.
A member of our community added on Facebook: "If it’s a procedure or full treatment that has been denied, ask for the qualifications of those on the committee that has rejected it. It could be just those out of high school with NO medical education." Knowing this information can make it easier for you to challenge a decision.
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
For example, you can start by saying, "I got a bill I don't understand." Then ask the following types of questions:
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 shows most people are paying much less.
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 wrotethis blog post about it as I was thinking about founding ClearHealthCosts.
Step 4: Ask the insurance company questions and follow the appeal process.
Know your plan. Find out if there's a reason the insurer says it doesn't pay for something, and get the rep to point you to the specific language.
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'sa 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.
Many times a bill from a provider and an insurance company's explanation of benefits tell the procedure for an appeal. Follow that procedure: where to send it, within what timeframe and so on. This is supposed to stop the clock on bill collections and keep a flawed bill from damaging your credit. If all you have is phone calls of complaint, you won't have that written record.
I'm repeating this because it's important: Get the provider and the insurer talking as quickly as possible. Sometimes it's a simple and easy-to-fix misunderstanding.
Here are some sample questions or points you can raise with the insurer:
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.
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 wrong. 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? It was a mistake. This happens more often than you think.
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% or 20% 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. Knowing what's going on with your bill will be crucial to knowing if you have to pay.
New federal protections against surprise and balance billing are scheduled to come into effect in 2022. Read more here.
Here's an explanation of balance billing, with some state-by-state regulatory information. It's slightly dated.
This more current state-by-state breakdown from the Commonwealth Fund will tell you what applies in your state.
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 price is so high, you have a hard time believing it's your responsibility. Here's a blog post abouta huge bill sent to a Seattle area man after emergency gallbladder 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.
Step 6. Call everyone again
Compile your 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.
One woman we talked to 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 have names like "medical billing advocates."
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.
One man was able to get his bill reduced by a lot. He thinks it was because he went to the hospital and talked to people. That's a possiblity. It's probably easier for a billing office person to dismiss you when you're on the phone and may be harder when you're face to face.
We heard from one person who cut her bill for a transvaginal ultrasound in half, saving $155.12, by negotiating with the provider using Medicare and other available pricing.
If all else fails, should you hire a lawyer? Maybe. Courts have weighed in for and against patients challenging surprise billing. 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. (Here'sour explainer about how the billing system works again.)
We frequently hear that providers will accept a lower rate if you offer to pay immediately. We also have heard that providers may be willing to put you on a payment plan, with a monthly payment of modest size. There are no hard and fast rules about this.
Some 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 receiving 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.
Nonprofit hospitals are required to have financial assistance plans, sometimes known as charity care, but you have to know to ask for it. Also, these plans can vary greatly from hospital to hospital. They tend to be means-tested, meaning that you'll qualify for free or discounted care if you can prove that you have a low income.
These programs vary greatly from institution to institution and state by state. Here'sa great explainer from U.S. News and World Report.
Here's a blog postdescribinghowawoman who was diagnosed with breast cancer while uninsured sought financial help before getting treatment.
Here's anotherpost abouthowanotheruninsuredwoman used 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.
A close look at charity options, crowdfunding and the like can be foundhere in a roundup by Helaine Olen at The Atlantic. That piece andthis one,in Slate by Jordan Weissman, more specifically on crowdfunding, point out that many crowdfunding campaigns do not reach their goals.
We are here to help, and also happy to hear your stories. So keep track, and keep us informed at info@clearhealthcosts.com.
