How to Dispute Medical Bills with Insurance

If you've ever received a medical bill that seemed too high or had mistakes, you're not alone.

About 35% of Americans face unexpected or wrong medical bills. The good news is that you have rights as a patient to challenge charges that seem incorrect or unfair.

This guide will help you understand how to dispute medical bills with your insurance company, from finding errors to filing formal appeals.

Why Medical Billing Errors Happen

Before we talk about how to dispute bills, let's look at why medical billing mistakes are so common.

Common Types of Medical Billing Errors

Medical bills can contain different types of errors that cause you to be charged too much:

Duplicate Charges

This happens when the same service or item is billed twice. For example, you might see two charges for the same blood test done on the same day.

These mistakes often happen when different departments record the same service. Duplicate charges can add hundreds or even thousands of dollars to your bill, especially for expensive procedures.

Incorrect Service Codes

Medical procedures use specific codes for billing, and using the wrong code can result in higher charges.

Medical coding is complicated, with thousands of possible codes. Even a small error can change a simple office visit into a comprehensive exam with a much higher price. These errors can happen when providers update their systems or when new staff aren't fully trained.

Out-of-Network Provider Errors

This happens when your insurance is billed for an out-of-network provider when you specifically asked for in-network care. This often occurs in hospitals where you might choose an in-network hospital but receive care from out-of-network doctors working there.

Anesthesiologists, radiologists, and pathologists are common providers who might be out-of-network even at in-network hospitals. These "surprise billing" situations can make your bill 5-10 times higher than the in-network rate.

Unbundling of Charges

This is when services that should be billed together under one code are instead split up and billed separately, causing higher charges.

For example, a surgery typically includes care before and after the procedure, but these might be wrongly billed as separate services.

Unbundling is considered a deceptive billing practice in many cases and can significantly increase medical costs.

Insurance Processing Errors

This happens when your insurance company applies the wrong policy rules, deductible amounts, or coverage levels when processing your claim.

Insurance companies handle millions of claims, and mistakes in how they apply your specific policy terms can occur.

These errors can lead to denied claims that should be covered or higher costs than your policy actually requires.

Taking time to review your bills carefully can save you a lot of money.

Immediate Steps to Take

When you get a medical bill that seems wrong, taking quick action is important. Here's what to do right away:

Request Detailed Documentation

Before disputing any charges, make sure you have all the necessary information.

Request an itemized bill from your healthcare provider that lists each service with the corresponding charge.

Also, get your Explanation of Benefits (EOB) from your insurance company, which explains how they processed the claim.

Compare these two documents to find differences in dates, services, or billing codes. Having these documents will help you point out specific errors rather than just questioning the total amount.

Make copies of everything in case you need to send the originals during the dispute.

Don't Pay the Bill Immediately

If you believe there's an error on your bill, don't rush to pay the full amount. Contact your provider's billing department to let them know you're disputing the charges. Ask if they can place a hold on your account while you investigate.

If the bill is already with collections, tell the collection agency in writing that you're disputing the charges.

Most providers will give you a reasonable time to resolve billing issues before sending accounts to collections, especially if you communicate early.

Researching Your Insurance Coverage

Understanding what your insurance should cover is crucial to disputing bills effectively.

Review Your Policy Documents

Before contacting your insurance company, read your Summary of Benefits and Coverage (SBC).

Check your policy's coverage rules for the specific services in question. Understand your deductible, copayment, and coinsurance responsibilities. Note any pre-authorization requirements that might apply.

Your policy documents are the contract between you and your insurer, so understanding these details strengthens your position when disputing charges.

Verify Network Status

If you're being charged out-of-network rates, confirm whether the provider was in-network on the date of service.

Check if you received care at an in-network facility but were treated by out-of-network providers. Find out if emergency care provisions apply, which often require in-network rates regardless of provider status.

The No Surprises Act, which took full effect in 2022, protects patients from many surprise out-of-network bills, especially in emergencies or when you couldn't reasonably choose your provider.

Contacting Your Insurance Company

When you're ready to dispute charges with your insurance company, preparation is key.

Prepare for the Conversation

Before calling your insurance company, have your insurance card, medical bills, and EOB available. Write down specific questions about the charges you're disputing. Be ready to take detailed notes during the call. Set aside plenty of time, as these calls can be lengthy.

Being organized makes your conversation more efficient and increases your chances of resolving the issue in one call.

Ask the Right Questions

During your call with the insurance representative, ask why the claim was denied or only partially covered.

Ask which specific policy provision applies to this decision. Find out if additional information is needed from your healthcare provider. Ask about the procedure for appealing this decision.

Write down the representative's name, department, and a reference number for the call. This information will be helpful if you need to follow up or take your dispute further.

Working with Your Healthcare Provider

Your healthcare provider can be an important ally in resolving billing disputes.

Contact the Billing Department

When speaking with your provider's billing office, explain specifically which charges you believe are incorrect and why.

Ask them to verify the billing codes against your medical records. See if they can resubmit the claim with corrected information. Request that they contact your insurance company directly if it's a coverage issue.

Healthcare providers deal with insurance companies every day and often have staff who can help resolve coverage issues more efficiently than you can alone.

Seek Support from Your Doctor

If the dispute involves medical necessity, ask your doctor to write a letter supporting the need for the treatment.

Request additional clinical documentation that might help your case. See if your doctor's office has a patient advocate who can help with insurance issues.

Many doctors are willing to help patients navigate billing issues, especially when it involves treatments they recommended.

Filing a Formal Appeal to Dispute Medical Bills

If initial conversations don't solve the problem, you'll need to file a formal appeal.

Internal Appeals Process

Every insurance company has a formal appeals process. Find the appeals instructions on your EOB or insurance company website.

Submit your appeal in writing before the deadline (typically 30-180 days after receiving your EOB).

Include all relevant documentation, including medical records, doctor's statements, and reference numbers from previous communications.

Clearly explain why you believe the claim should be covered under your policy. Keep copies of everything you submit.

Insurance companies must review your appeal and respond within specific timeframes, typically 30-60 days for non-urgent appeals.

Check your EOB or plan documents for the exact deadline, as it varies by insurer.

External Review Options

If your internal appeal is denied, you have the right to request an external review by an independent third party. External reviews are conducted by organizations not affiliated with your insurance company.

Your insurance company must provide information on how to request an external review. The external reviewer's decision is typically binding on the insurance company.

The Affordable Care Act established external review rights for most health insurance plans, giving patients an important way to dispute denied claims.

Escalation Options

If standard appeals don't resolve your dispute, you have additional options.

State Insurance Department

Your state's insurance department or commissioner's office can help. They regulate insurance companies operating in your state and can clarify if your insurer is following state insurance laws.

Many offer consumer assistance programs for health insurance disputes and can sometimes mediate between you and your insurance company.

You can find your state insurance department's contact information on the National Association of Insurance Commissioners website at NAIC.org.

Federal Assistance

For certain types of insurance plans, different agencies can help:

Employer self-funded plans are regulated by the Department of Labor's Employee Benefits Security Administration.

Medicare plans have specific appeals processes through the Centers for Medicare & Medicaid Services. Federal marketplace plans have appeals options through Healthcare.gov.

Understanding which agency oversees your specific type of insurance helps direct your complaint to the right authority.

Negotiating Medical Bills

Sometimes the issue isn't with your insurance but with the overall charges.

Ask for Discounts

Even after insurance processing, you can often negotiate remaining balances. Many providers offer discounts if you can pay the full amount right away. Ask about financial assistance programs or charity care policies. Look into interest-free payment plans.

Healthcare providers often prefer getting partial payment directly from patients rather than sending accounts to collections, where they typically recover only a fraction of the amount owed.

Professional Help Options

For complex or high-dollar disputes, consider getting professional help. Medical billing advocates specialize in finding errors and negotiating bills.

Some employee assistance programs offer medical billing review services. Nonprofit organizations in your community might offer free help with medical billing issues.

Professional medical billing advocates typically charge either a flat fee or a percentage of the money they save you, often 25-35% of the reduction.

Preventing Future Billing Problems

Taking proactive steps can help avoid billing disputes in the future.

Before Receiving Care

To minimize future billing surprises, verify that providers are in-network before scheduling appointments. Get pre-authorization when required by your insurance.

Ask for cost estimates for planned procedures. Get referrals in writing when needed.

Many insurance companies and healthcare providers now offer cost estimation tools that can help you understand your potential costs before receiving care.

Keep Organized Records

Maintaining good records of your healthcare helps with future disputes. Save all medical bills and EOBs for at least a year. Write down phone conversations with providers and insurers. Keep a health journal of dates and types of care received. Save receipts for all medical payments.

Digital tools like healthcare apps or simple spreadsheets can help you track this information more easily.

Special Scenarios

Some medical billing situations require specific approaches.

Emergency Care Disputes

For emergency care billing issues, the No Surprises Act protects patients from most surprise bills for emergency services.

Insurance must cover emergency care at in-network rates, regardless of where you receive it. Balance billing is generally prohibited for emergency services and certain non-emergency services at in-network facilities.

If you receive a bill that doesn't follow these protections, specifically mention the No Surprises Act in your dispute.

Hospital Billing Issues

Hospital bills are often the most complex. Request a complete review of charges if the bill seems too high. Ask for a patient advocate from the hospital to check your bill. Look for common hospital billing errors like incorrect room charges or duplicated supplies.

Many hospitals have financial counselors who can help explain charges and identify potential errors or assistance programs.

Medicare and Medicaid Considerations

Government insurance programs have specific dispute processes. Medicare recipients should start with a "redetermination" request. Medicaid disputes typically begin with your state's Medicaid agency. Both programs have multiple levels of appeal available.

For Medicare, the Medicare Rights Center and State Health Insurance Assistance Programs (SHIPs) offer free help with billing disputes.

The Bottom Line

Disputing medical bills takes patience and determination, but the financial benefit can be substantial.

Even when you're initially told "no," continuing to appeal through proper channels often leads to better outcomes.

Remember that billing errors are common, and insurance companies sometimes make mistakes in processing claims. By carefully reviewing your bills, understanding your coverage, and following the proper dispute procedures, you can often reduce your medical expenses significantly.