Receiving a medical bill can elicit anxiety, especially since it can be hard to predict what you’ll be charged for a doctor’s visit, a procedure or any other medical service.
If you get an alarmingly high bill, you might feel too overwhelmed to deal with it. If it’s a small bill, you might be tempted to pay it without giving it a once-over, just to make it go away. But it’s worth scrutinizing every bill you receive, given that up to 80 percent of medical bills potentially contain errors.
An Equifax audit found that hospital bills of $10,000 or more contained an average of $1,300 of billing errors; a study published by the American Medical Association showed that after visiting an in-network hospital, 4 in 10 patients faced surprise bills. In 2016, the average price of a surprise bill was $628, up from $220 in 2010, according to the study.
“People don’t like to look at their medical bills,” says Jon Hess, CEO of Athos Health, a Minnesota-based company that helps people decipher medical bills. “If a bill is within reason, people want to trust their doctor or their hospital. But many times, they’re paying more than they have to.”
You should comb every bill carefully for errors, Hess says. It’s understandable if the idea of examining lists of billing codes doesn’t excite you. But the task will seem less daunting if you understand what’s included on your bill — and how to look for things that shouldn’t be there. So we broke down the process for you. Read this guide before you read your next medical bill.
When will you get a bill?
There aren’t regulations that dictate how long after a visit or a procedure you should receive a bill. It could be two weeks, or it could be a year. After a visit, a provider submits a claim to a patient’s insurance company. Then the claim needs to be processed, which can take time. Hospital billing procedures also vary. One facility might send bills immediately following care, while another waits to send them in batches. If it’s been two months and you haven’t received a bill yet, you may want to call your provider’s office and ask for it, says Caitlin Donovan, senior director of public relations at the National Patient Advocate Foundation.
How are medical bills set up?
Most doctors or hospitals will send you a summary medical bill that states how much money you owe, with very few details about the services you received.
You’re entitled to an itemized bill, says Donovan, but you usually have to request it.
If you get a summary bill, ask for an itemized one so you know what you’re being charged for. An itemized bill will include a line for each service and medical supply you received, with the dollar amount for each one.
Your bill will come directly from your doctor or the hospital where you received care. It’s not to be confused with an explanation of benefits form, or EOB, which is a letter from your insurance provider explaining what services and supplies your health plan covered. An EOB says “not a bill” on it.
What should you know about all the codes on bills?
In recent years, the number of medical billing codes has jumped, from about 17,000 to 150,000. With such a massive number of codes, you can’t expect to know every single one you come across. But understanding how codes work and how to look them up can help you spot potential errors.
There are a few types of codes:
- HCPCS Level I codes, or CPT codes, are used by all U.S. providers, and they consist of five digits that correspond to different procedures or tests. They’re often called service codes on your bill.
- HCPCS Level II codes correspond to supplies or products used during your visit. Many times, these codes start with a letter instead of a number, but they’re also called service codes.
- ICD-10 codes identify diagnoses. In the U.S., every billed service with a CPT code has to link to an ICD code to make sure the treatment matches the diagnosis. If a doctor is treating you for a single condition, all ICD-10 codes should be the same.
- Revenue codes are specific to a facility. They identify the dollar amount linked with a procedure.
One way to look up HCPCS or CPT codes, to make sure you’re being billed for the care you received, is the Medicare code lookup. Ignore the pricing information listed unless you’re a Medicare recipient since Medicare’s pricing is typically much lower than what private insurers pay. Enter the code on your bill, select “All Modifiers,” and hit submit for an explanation of the code.
What are some common mistakes?
Common errors range from a misspelled name to the wrong code. “It’s really easy to make a coding error,” says Donovan.
When Donovan was on maternity leave, she tracked the number of errors in the multiple bills she received after the birth of her son. Out of 16 bills, half had errors, including listing an insurance company that wasn’t hers and billing for the same service twice. Not questioning the bills would have left Donovan short $647 she didn’t owe.
Hess, whose 15-year career as a healthcare consultant included working on systems used by hospitals to issue and collect bills, was incorrectly billed more than $100,000 for his daughter’s heart surgery after a clerical error.
Common mistakes include:
- Coding errors: The person entering codes used the code for a brand name drug when you took a cheaper, generic one. Or your sprained ankle was coded as a break.
- Duplicate charges or inflated quantities: You’re charged for the same service multiple times. Or a coder adds an extra zero, and you end up being charged for 100 pills instead of 10.
- Treatments you didn’t receive: While you were in the hospital, your doctor scheduled you for an MRI, but then decided you didn’t need it. The test might still end up on your bill if no one removed it from your chart.
- Incorrect surgery times: Operating room time is charged by the minute. If the time you spent in surgery is marked down incorrectly by a coder, you could be paying more than you should. If the time listed on the bill seems off, ask to see your medical record to see when your surgery started and stopped.
- Wrong room fee charges: For hospital stays, it’s not uncommon for someone who stayed in a shared room to be charged a private room fee. Sometimes, coders also mark down the wrong number of days, inflating bills.
- Insurance issues: Your health insurance denies you coverage — either incorrectly or legitimately.
What should you check for when you get your bill?
First of all, keep your EOB handy, Hess says. Your EOB should arrive before your bill does. If it says you owe something and you don’t get a bill, ask your provider or the hospital why they haven’t sent one. It’s possible your bill went to the wrong address. Unpaid bills can be sent to a collections agency, which could potentially affect your credit score.
When your bill arrives, check that your name, address, insurance information — including your health insurance provider, policy and group number — and the dates you received care are all correct. Then, make sure the amount on your bill matches what the EOB says you owe. If it doesn’t, call your insurance company and ask about the discrepancy.
“Sometimes doctors order medications in a hospital setting, but the patient doesn’t take it, yet gets billed for it anyway.”
If you’ve requested an itemized bill, review each line item to make sure it reflects a service or product you received. “Sometimes doctors order medications in a hospital setting, but the patient doesn’t take it, yet gets billed for it anyway,” says Donovan. You’ll also want to make sure you weren’t billed for any medications you brought from home.
Review the ICD-10 codes on your bill to make sure they match the reason you were in the hospital or the condition for which you were treated. Look for duplicate charges, and if you had surgery, review the timed operating room charge to make sure it squares with how long the doctor said your surgery took. Finally, add up the individual charges to make sure they equal the total amount listed on the bottom of your bill.
You found a mistake — now what?
Call your doctor or the hospital and flag it. Sometimes it’s an easy fix. Even so, be prepared for multiple phone calls. Donovan says that when one of the Foundation’s advocates works with a patient, it takes an average of 22 phone calls to get an issue resolved.
Donovan suggests asking for a direct phone number for a specific billing professional so you don’t have to keep reexplaining your issue to different people. If the prospect of disputing charges is too overwhelming, you could hire a professional medical billing advocate. For a fee, they’ll review your bill and work with your provider to correct errors or negotiate charges.
“Having an advocate generally leads to better outcomes for the patient,” Donovan says.
How much time do you have to pay your bill?
Typically, you have anywhere from three to six months before a provider or hospital sends a bill to collections. “Some providers are more aggressive than others,” Donovan says.
If you’re not paying the bill because you’re appealing a denial from your insurance company, write a letter to your provider explaining the situation and ask them to put your account on hold. Ninety-nine percent of the time, Hess says, the provider or hospital will do so for 30 to 90 days.
What should you do if your bill is sent to a collections agency?
Don’t panic, and don’t jump to pay it right away.
Maybe your provider mailed your bill to the wrong address so you never received it. If that’s the case, put it in writing that you’re contesting the bill. The collections agency will then have to validate the bill with your provider. That gives you time, because the agency can’t contact you again for payment until that process is complete.
Meanwhile, ask your provider for an itemized bill and review all charges for accuracy. If the bill is a big one, use the time to take stock of your finances. If you can pay your provider in full, that’s your best bet, says Donovan.
“You don’t want to mess with your credit score,” she says. You could also settle with the collections agency, which might mean paying less. But your credit score could also suffer. “Weigh that carefully,” Donovan says.
If your bill seems high, can you negotiate?
All medical bills are negotiable. Doctors and hospitals want to get paid, so they’ll work with patients on a discount and a lump sum settlement, or a payment plan, says Hess. A medical bills survey from The Kaiser Family Foundation and the New York Times found that more than half of people with medical bill problems worked out a payment plan. “We can always get them down,” Hess says.
Know what you can pay and research a fair price for the service. Look up the Medicare rate for the service you received, or use the Healthcare Bluebook. That will be your starting point for what you’ll offer to pay to settle.
Hess looks up the Medicare price and then multiplies that figure by 1.5, realizing the negotiation process will likely bring the final price up to twice that of Medicare. Explain how you arrived at your number when negotiating, he says.
Are there any protections for patients who can’t pay?
Twenty-eight states have laws in place to help patients who get surprise medical bills. New York passed the first one in 2014. Under its surprise bill law, patients no longer have to pay out-of-network charges for surprise out-of-network services that are higher than the patient’s in-network copayment, deductible or coinsurance rate.
So, for example, if a patient in New York was treated at an in-network hospital but saw an out-of-network doctor because no one in-network was available, they’d be let off the hook for the potentially massive medical bill.
A working paper by Yale professors found that out-of-network bills in New York dropped by 34 percent since the law took effect. New Jersey recently passed a similar law, and Congress has eyed the New York law as a possible model for similar national legislation.
What can you do in the first place to prevent big bills?
Ask your doctor to get a predetermination from your insurance company before you have a procedure, Hess says. A predetermination is a review by your insurer’s medical staff to decide if they agree you need the treatment.
If your insurance agrees, you’re protected, Hess says, and you don’t run the risk of being denied coverage and ending up with a big bill. Most providers don’t do a predetermination automatically, he says, so you’ll probably need to ask your provider for one.
Donovan’s No. 1 tip for avoiding costly medical bills is to always stay in-network. Understand your healthcare benefits and what’s covered, adds Hess.
“Medical billing is not an exact science.” says Hess, “It’s really an art. You have to ask questions and you have to negotiate.”