Inside: Are you looking for answers on how to win a medical bill dispute? Read on to find out how I disputed a $12,000 surprise medical bill and won.
I’ll never forget it.
I was in the middle of receiving IVIG treatment at Vanderbilt when I received a phone call from my insurance company telling me that they would not cover the cost of the treatment.
I went ballistic.
Not, like, kind of flipped out. I mean I altogether lost my shit screaming at the top of my lungs in front of all the other nurses and patients receiving their treatments.
No one left the building that day with any apprehension of how I felt about insurance companies.
I was already up to my neck in medical bills from getting diagnosed with a rare neurological disease at 26-years-old. Now, I had just found out that I would be responsible for a $12,000 surprise medical bill.
I was determined to fight this medical bill dispute.
How do I dispute a medical bill charge?
According to an article published in JAMA in February 2020, “More than half of Americans have received a surprise medical bill.” Surprise medical bills are extremely common.
Frankly, I had no idea. Looking back, I should have requested a pre-approval from the insurance company to ensure I was covered before the treatment.
The best thing for you to do to not have to dispute a medical bill is to get a pre-approval from your insurance company before you have the test, procedure or treatment.
Basics of disputing a medical bill:
- This is going to be a long and tedious process. For perspective, I spent around 30 hours researching how to dispute a medical bill and gathering documents.
- You have to get organized. I recommend purchasing a medical binder to keep all of your information in one spot. It’s going to be a lot tougher if you can’t pull up a piece of information quickly and easily.
- Take lots of notes. You must write down the date, time and name of every person that you speak with during the process.
- You’ll be making lots of phone calls. This means calling multiple doctors, your insurance company, the state’s insurance commission, patient advocates, etc.
What happens if you refuse to pay medical bills?
Like most other bills, if you refuse to pay a medical bill it will likely get sent to collections.
If your medical dispute is complicated, it’s probably going to take a while to resolve. You should call the medical provider and ask them to hold off on sending your medical bill to collections. Also, try to get the agreement in writing.
1. Review Your Bill & Explanation Of Benefits
After getting stuck with a surprise medical bill, the first thing that you want to do is review the bill against your explanation of benefits. You’ll probably receive a denial letter in the mail that looks something like this:
Save this in a safe place for later.
The next thing that you’re going to do is request a copy of the itemized bill from your provider’s office. For instance, I needed to call Vanderbilt and ask them for a copy of the bill for the treatment I received on September 21st.
Once you receive the bill and the denial letter, review both of them to get a better understanding of why they might have denied covering the cost.
Next, you’re going to call your insurance company and ask them for an explanation of benefits. My insurance company sent me the EOB through a secure message on the patient portal.
What Is An Explanation Of Benefits?
An Explanation of Benefits is a statement from your health insurance company providing details on payment for a medical service you received. It explains what portion of services was paid by your insurance plan and what part you’re responsible for paying.
You’ll typically see something like the following:
- Amount Billed By Provider (this is how much the doctor or hospital charges)
- Plan Discounts (this is a discount negotiated by your insurance company)
- Amount paid by the insurance company
- Amount you will owe the provider
- Most Explanation of Benefits forms will also include information about your deductible, co-pay, co-insurance, and more.
For example, my treatment was not covered, so the explanation of benefits had a code or error, with a short explanation as to why it’s not covered. The denial may be as simple as someone accidentally entering in the incorrect code number.
2. Find a patient advocate
Another great option to help assist you in the medical bill dispute process is finding a patient advocate. Call your hospital, insurance company and state insurance commissioner’s office (the agency in charge of making sure insurance providers comply with the law) to see if there are any available Patient Advocates to help you.
Depending on your situation, you may have to pay for the service. However, if the costs of working with the patient advocate are less than the amount you owe to your insurance company, it may still be worth it.
I found a free Patient Advocate through the Patient Advocate Foundation. I was eligible for their free services because I had a chronic illness that would not improve.
In my case, the patient advocate from the Patient Advocate Foundation completely took over all responsibility. All she needed me to do was provide her with my medical records and she took it from there. She would do three-way calls with the insurance company and my doctors, where I would never even have to speak.
Make copies of everything you send with your appeal for your records. If you are sending your appeal by mail, ensure you send it with tracking. If faxing, be certain to verify successful transmission of the fax.
You can look for advocates on the websites of professional membership groups such as the Alliance of Professional Health Advocates, the National Association of Healthcare Advocacy and the Alliance of Claims Assistance Professionals.
3. Gather evidence
Once you have all of the proper documentation, call your insurance company and ask the customer service line directly: “What needs to happen for this to be covered?”
The insurer may be missing a key medical record indicating that a service was necessary, or they have entered the wrong code when your claim was submitted.
Do not get off the phone until you have an answer to:
- Why the claim was denied
- What the insurance needs in order to reverse the denial
For Instance, the insurance company denied my treatment, because it was deemed “medically unnecessary.” The EOB stated that they would only cover the treatment if I had a primary diagnosis of MMN. At the time, I had a differential diagnosis of MMN, BAD, ALS & PMA. This meant that I needed to show reasonable evidence that MMN could be my primary diagnosis.
How to gather evidence to reverse an insurance denial?
The first thing that you should do is reach out to the doctor who recommended this treatment, and ask them for medical studies that show why they recommended this particular treatment. They should be able to point you in the right direction as far as credible research.
At the same time, you should go to PubMed and review all of the research that you can find that would help prove your case on why your insurance company should have covered your treatment.
4. File an internal insurance appeal
Once you have gathered all of the necessary documents and have a case, it’s time to file the insurance appeal. You can file an appeal up to 180 days after you are notified of a denial. The explanation of benefits you get from your insurance company will have information about how to file.
Basically, your case will be sent to a different review team of the insurance organization. They will review it and decide whether the appeal should be reversed or not. It is not uncommon for the first appeal to be denied, since the review team is associated with the insurance company.
What happens if the internal appeal is denied?
If your internal appeal is denied, don’t worry. You can request an “external review” by an independent organization accredited to review health care decisions. Appeal rights depend on the state you live in and the type of health plan you have. For more information, visit Appealing a health plan decision.
An external review either upholds your insurer’s decision or decides in your favor. Your insurer is required by law to accept the external reviewer’s decision.
My first appeal was denied, but then it was submitted for an external review and it was approved. In between the first and second appeals, I asked my doctor to write a formal explanation on why be insurance denial should be reversed. I then submitted this additional information to the external review. I believe this really helped me overturn the denial.
5. Find legal help
If both your internal and external appeals were denied you can still seek legal counsel. Make sure to find an attorney that specializes in medical billing disputes.
Of course, you would probably only want to see if this option if the medical costs are greater than the cost of a lawyer. Most lawyers will allow a free initial phone call to determine if they can assist you or if you even have a case. They’ll tell you potential costs, too.
For more information on finding an attorney, visit Medical Billing Advocates and Lawyers – Who to Use and When
6. Try negotiating
If you aren’t able to get the denial overturned, ask the medical provider’s billing office to reduce what you owe. This is actually not that uncommon.
They would rather get some money than none at all.
Tell them specifically how much you can afford and offer to pay a lump sum. I recommend starting at around 50% of the bill.
In addition, many medical offices also offer interest-free payment plans, and most hospitals have some kind of financial assistance program based on income.
Final Thoughts on 6 Steps to Win a Medical Bill Dispute (+ FREE Printable Action Plan)
Filing an insurance appeal is a stressful experience, but following the steps above will help you win a medical bill dispute. You’re entitled to fair coverage.
One of the most common reasons that appeals are not overturned is because patients miss deadlines. Check out the printable action plan to make sure that all your bases are covered when disputing a medical bill.
Good luck! I hope this helps!
Have you ever had a medical bill dispute? What did you do? Tell me in the comments below!
Allie Schmidt is a rare disease advocate and disabled mom living with motor neuron disease. She founded Disability Dame in 2020 to provide tips to other moms living with disabilities and chronic illnesses.
In her spare time, you can find her traveling with her husband (she's been to 38 states and 16 countries!), watching reruns of Survivor, or tending to her near-constant sunburn from spending too much time outside. You can follow her adventures here.