Have you ever opened a healthcare bill and thought "this must be a mistake"? You're not alone. A 2020 research study found that 1 in 5 insured adults received an unexpected medical bill. Another more recent one found that health insurance claims' denials across the board are on the rise.
From a consumer standpoint, well, the situation is rather depressing. (You don't have to do much investigation to figure out who wins from widespread denial of claims.)
Don't lose heart. What many people may not know is that medical bills aren't always accurate or set in stone. If you believe there's an error or your health plan and the medical facility that provided care haven't fairly considered your claim, you have the right to challenge it. This process is referred to as appealing a bill, and it can be daunting and stressful, particularly if you're unsure where to begin.
Let's unravel the steps involved to make it more manageable.
Start by inspecting the document
First things first, is the document really a bill? It may be an Explanation of Benefits (EOB) form sent by your health insurance company detailing the sometimes startling cost of care you've undergone. Often they are lengthy (as in many, many pages) and only explicitly call out the smaller sum you're accountable for if you look carefully.
If it is a bill and the amount is a surprise, inspect it:
- Are there adjustments from the insurer? If not, then this is an excellent reason to explore more.
- Are there items in the bill that look incorrect or vague? If yes, then this, too, is a reason for more investigation.
- Is the claim letter (if you received one) unclear and maybe sound like a bunch of gibberish? If yes, then you deserve more clarity.
Now you know you need to dig further. But where do you start?
Understand your health plan before making any calls
Take time to familiarize yourself with all your health plan policy benefits, including deductibles or copayments you may be responsible for, before contacting the health insurance company. Knowing this information will help you determine if a bill has been incorrectly charged and will lead to more productive calls. Hopefully, this step will also save you time! When dealing with insurance providers, waiting on hold is inevitable, and doing it many times can be headache-inducing.
Make sure the provider billed your insurer
Now that you've gotten some of the research down, let's move to the bill. The 'final' bill should note adjustments or payments made by your insurer. If these are missing, contact your provider's office staff and ask if they've submitted a claim to your health plan. If they haven't, urge them to do so as soon as possible. If they have, ask why it was denied, and then get ready to contact your insurer.
Keep in mind if your provider is not "in-network" with your health plan’s network, they might not submit your claims at all, even if you request them to. The responsibility of submitting the claim then falls on your shoulders. Contact your insurance provider to find out the best process for submitting a claim.
Request a detailed bill
Sometimes invoices can seem vague — you're really sure what exactly you're being charged for. A detailed or itemized bill breaks down all the services you received so you can see the specific fees. This can include the cost of tests, use of medical equipment, hospital stay charges, and facility fees.
Remember, it's within your rights to ask for this detailed bill. Don’t hesitate to request one from your provider if you think it's necessary.
Know the law: The 'No Surprises Act'
The federal No Surprises Act, in effect since 2022, provides a safety net for unforeseen medical events. If you find yourself in an emergency room of a hospital that partners with your insurance plan, this law ensures you won't face “balance billing,”—which basically means extra charges from out-of-network physicians. These surprise bills often inflate the cost of emergency visits by hundreds to thousands of dollars.
If you've never been to an ER and suffered a balance billing issue, you might be wondering why this federal legislation is needed. Here's a scenario that was happening too often.
You've had an accident and been rushed to the nearest emergency room. Even though you've done your best to ensure that the hospital is in-network, you find out later that the ER doctor who treated you is not. You weren't really in a position to interview doctors about their network status. Besides, it's first-come-first-serve in the ER. Weeks later, you receive a bill for thousands of dollars. The hospital has charged your insurance company at the in-network rate, but the out-of-network ER doctor sends you a separate bill for the remaining amount. This is called balance billing, and it's a financial blow that can feel out of left field.
With the No Surprises Act, the scenario above is designed to be a thing of the past. The act applies to non-emergency care from out-of-network providers within in-network hospitals, outpatient facilities, and even ambulatory surgery centers—if these facilities participate in your insurance plan’s network.
While there are still some loopholes, for instance, ground ambulance services aren't covered, and the law is actively being debated among states, knowing some of these legal boundaries may give you more arguments for your appeal.
Filing an appeal
Once you understand the details of your health plan and the billing issue at hand, it's time to file an appeal. The first step is to contact the insurance company and explain why you are appealing the charge. You'll need to be specific about the reason you are appealing and where they have erred. A letter from your doctor or any evidence (like a medical record) can help but isn't required.
Once you have sent in the appeal, it will be reviewed by the insurance company, and they will make a decision usually within 30 days.
Tips for filing a successful appeal
Here are a few key strategies to keep in mind when writing your appeal.
1. Call the health insurance company to make sure you understand the correct process for filing the appeal with your health insurance company and the deadlines for doing so! Every company has a process, and each one is different. Sadly, it's often not easy to find this information on the health insurer's website, so calling to verify is your best bet. While you have the insurance company on the phone, get more details about the reasons for your denial — useful info for writing your appeal letter.
2. Write a professional letter and this information:
- Address the insurance company and the person who denied your claim
- State the reason for your letter and provide a brief overview of your case.
- Include copies of supporting information (medical information, etc.)
- Keep it respectful! (While likely justified, leave the anger out of the letter.)
3. Keep a record of all communication with your health insurance company. Include the dates of the calls, names of people you spoke with, and the information discussed and copies of your appeal letters.
4. Be persistent. If your first appeal is denied, don't give up. You have the right to ask for additional review.
5. Stay organized. The appeals process can be lengthy and complicated, but if you believe you've been wrongly charged, it's worth the effort to fight. Your health and wallet will thank you.
Worth repeating: Don't give up after your first denial
Your first appeal may get denied. Don't lose heart! Persistence is key in these situations (and, really, anything having to deal with health insurance claims). If your initial appeal is rejected, gather more detailed information or evidence to strengthen your case.
For example, if you didn't consult your provider in the first appeal, now's the time to try. Gather your medical history or treatment protocol that justifies the claim, a letter from your doctor validating these things helps, too.
Remember, the goal is to clearly establish why the service was medically necessary and should be covered by your health plan. This process is tedious and time-consuming, but it's essential in ensuring you aren't burdened with unjust healthcare costs.
If your second appeal is denied, consider seeking out a patient advocate or a lawyer who specializes in health insurance issues to help guide you through the process.
StretchDollar aims to make health benefits better for small businesses. This includes equipping people with the information they need to manage their coverage better. Read more about why we started StretchDollar.
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