Healthcare Billing Disputes: Hospital Bills, Insurance Denials, and Medical Debt

Medical bills are confusing, often incorrect, and sometimes shockingly high. The Centers for Medicare & Medicaid Services (CMS) provides official guidance on the No Surprises Act and healthcare billing rights. Understanding your rights - especially under the No Surprises Act - helps you fight unfair charges, appeal insurance denials, and manage medical debt without destroying your finances.

Common Billing Problems

Hospital Bill Issues

• Surprise bills from out-of-network providers
• Charges for services not received
• Duplicate charges
• Incorrect coding
• Facility fees not disclosed
• Balance billing after insurance

Insurance Denials

• Claim denied as not medically necessary
• Prior authorization issues
• Out-of-network denials
• Coding errors causing denial
• Experimental treatment denials

Billing Errors

• Charges for cancelled procedures
• Wrong patient charges
• Incorrect dates of service
• Unbundled charges (should be grouped)
• Upcoding (billing for more expensive service)

No Surprises Act Protection

What's Protected

• Emergency services (any facility)
• Out-of-network providers at in-network facilities
• Air ambulance from out-of-network providers
• Can't require you to waive protections

Your Rights

• Only pay in-network cost-sharing
• Out-of-network care counts toward deductible
• Must receive good faith estimate (uninsured)
• Can dispute bills exceeding estimate by $400+

How to Use Protection

1. Check if bill is protected situation
2. Calculate what in-network would cost
3. Dispute any amount above that
4. File complaint if provider won't comply

Disputing Hospital Bills

Request Itemized Bill

• You have right to detailed breakdown
• Every charge should be listed
• Compare to services actually received
• Look for duplicate or unknown charges

Review for Errors

• Services you didn't receive
• Duplicate charges
• Incorrect dates
• Wrong insurance information
• Charges after discharge date

Dispute Process

1. Request itemized bill
2. Identify specific errors
3. Put dispute in writing
4. Request investigation
5. Escalate if not resolved

Appealing Insurance Denials

Internal Appeal

• Must be allowed by law
• Usually 180 days to file
• Request all denial information
• Submit supporting documentation
• Get decision within 30-60 days

External Review

• Available after internal appeal denied
• Independent third party reviews
• Decision is binding on insurer
• No cost to you
• Usually 45 days for decision

Appeal Tips

• Get doctor's letter of medical necessity
• Include all relevant records
• Cite plan language that supports coverage
• Be specific about why denial is wrong
• Meet all deadlines

Negotiating Medical Bills

Request Financial Assistance

• Nonprofit hospitals required to offer
• Based on income and family size
• May reduce or eliminate bill
• Ask for application

Negotiate Payment

• Ask for cash-pay discount
• Request payment plan
• Offer lump sum settlement
• Compare to Medicare rates

Negotiation Tips

1. Research fair prices (Healthcare Bluebook)
2. Start with 50% reduction request
3. Get any agreement in writing
4. Pay agreed amount promptly
5. Don't ignore bills - negotiate early

Medical Debt Protection

Credit Reporting Rules

• Medical debt can't appear for 1 year
• Paid medical debt removed from reports
• Debt under $500 excluded
• Can dispute inaccurate reporting

Collection Protections

• Right to validate debt
• Dispute inaccurate amounts
• Request payment verification
• Negotiate with collectors

What Collectors Can't Do

• Harass or threaten
• Call at unreasonable times
• Discuss debt with others
• Misrepresent debt amount
• Sue after statute expires

Filing Complaints

Where to Complain

• State insurance department: Insurance denials
• CMS: No Surprises Act violations
• State AG: Billing fraud
• CFPB: Medical debt collection
• State medical board: Provider misconduct

What to Include

• Dates of service
• Provider and facility names
• Insurance information
• Bills and explanation of benefits
• Documentation of dispute attempts

Special Situations

Emergency Room Bills

• No Surprises Act applies
• Can't balance bill for emergency
• Facility fees may be separate
• Request itemization

Ambulance Bills

• Air ambulance protected
• Ground ambulance NOT covered by No Surprises Act
• May still be able to negotiate
• Check state laws

Out-of-Network Providers

• Protected at in-network facilities
• Not protected if you chose out-of-network
• Can still negotiate
• Appeal if mis-coded