How to Appeal an Unexpected Medical Bill

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, why certain services weren’t covered, and what you need to do to fix it.

In a disputed or unexpected medical bill, denials of claims for in-network procedures are usually the easiest to resolve, says Katalin Goencz, a medical insurance and reimbursement specialist in Stamford, Connecticut. 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 For example, an error in how a procedure was coded could lead to a denial, as could an outdated insurance card.

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.

Most insurance companies allow you to appeal a claim for an unexpected medical bill or other disputed bill 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 No Surprises Act 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.

Related: ‘Never Pay the First Bill’: Reporter Marshall Allen has a book full of instruction on dealing with an unexpected medical bill

Rivan V. Stinson is a staff writer at Kiplinger’s Personal Finance magazine. For more on this and similar money topics, visit Kiplinger.com.

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