Medical Billing Disputes and Errors

Medical billing errors affect approximately one in three Americans, with studies suggesting that 80% of medical bills contain mistakes. From surprise balance bills to incorrect coding to charges for services never received, these errors can result in thousands of dollars of unwarranted charges. This comprehensive guide explains your rights under federal and state law, how to identify and dispute billing errors, negotiate lower bills, and protect yourself from unfair medical debt collection. For official federal guidance on the No Surprises Act, visit CMS.gov.

Common Medical Billing Errors

Before disputing a bill, understand the most common types of errors:

Error Type	Description	How to Identify
Duplicate Charges	Same service billed multiple times	Compare dates and service codes
Upcoding	Billing for more expensive procedure than performed	Request itemized bill, compare CPT codes
Unbundling	Billing separately for services that should be bundled	Look for related procedures billed individually
Incorrect Patient Info	Wrong insurance, policy number, or personal info	Verify all personal information
Services Not Rendered	Charges for services you didn't receive	Compare to medical records
Balance Billing	Billing for amount above what insurance paid	Check if provider is in-network
Operating Room Time	Overcharging for time in surgery	Request operative notes, verify times
Canceled Services	Charges for appointments you canceled	Check appointment records

Your Legal Rights

Multiple federal and state laws protect patients from unfair medical billing practices:

The No Surprises Act (2022)

The No Surprises Act (NSA) is a landmark federal law that protects patients from surprise medical bills. Key protections include:

• Emergency services: Cannot be balance billed for emergency care, even at out-of-network facilities
• Air ambulance: Cannot be balance billed for air ambulance services from out-of-network providers
• Non-emergency at in-network facilities: Cannot be balance billed by out-of-network providers at in-network facilities without advance notice and consent
• Good faith estimates: Uninsured or self-pay patients must receive a good faith estimate before scheduled services
• Dispute process: If bill exceeds estimate by $400+, you can dispute through patient-provider dispute resolution

Right to an Itemized Bill

Federal law gives you the right to receive a detailed, itemized bill upon request. This itemized statement must include:

• Description of each service or item
• CPT/HCPCS procedure codes
• Dates of service
• Individual charges for each item
• Provider information

HIPAA Medical Records Rights

Under HIPAA (45 CFR 164.524), you have the right to access your medical records to verify billing accuracy:

• Providers must provide copies within 30 days (up to 60 with extension)
• Can charge reasonable copying fees ($0.05-$0.25 per page typical)
• Cannot withhold records due to unpaid bills (in most states)
• Electronic copies must be provided if maintained electronically

No Surprises Act Protections

The No Surprises Act provides extensive protections for patients receiving care:

Situation	Protection	Your Maximum Responsibility
Emergency Services	Full balance billing protection	In-network cost-sharing amount only
Out-of-Network Provider at In-Network Hospital	Protected unless you consent in advance	In-network cost-sharing
Air Ambulance	Full balance billing protection	In-network cost-sharing
Uninsured/Self-Pay	Good faith estimate required	Estimate + $400 (can dispute if exceeded)

How to File a No Surprises Act Complaint

1. Gather documentation: bills, EOBs, good faith estimates
2. File complaint online at CMS No Surprises Help Desk
3. For disputes over $400 above estimate, initiate patient-provider dispute resolution within 120 days
4. Provider must participate in resolution process
5. Decision typically within 30 days

Insurance Claim Appeals

If your insurance denies a claim or pays less than expected, you have the right to appeal:

Internal Appeal Process

1. Request denial in writing: Ask for the specific reason and policy provision
2. Review your policy: Understand what's covered and exclusions
3. Gather documentation: Medical records, doctor's notes, supporting evidence
4. Submit written appeal: Typically within 180 days of denial
5. Include medical necessity letter: From your treating physician
6. Response deadline: 30 days for pre-service claims, 60 days for post-service

External Review

Under the ACA (42 U.S.C. 300gg-19), you have the right to external review if internal appeal fails:

• Must be offered for denials based on medical necessity, appropriateness, or experimental treatment
• Independent reviewer not affiliated with insurer
• Decision typically within 45 days (72 hours for expedited urgent cases)
• Decision is binding on the insurer

Negotiating Medical Bills

Even valid medical bills can often be reduced through negotiation:

Negotiation Strategies

Strategy	How It Works	Typical Reduction
Ask for Cash/Self-Pay Discount	Offer to pay immediately for reduced rate	20-50%
Medicare Rate Comparison	Request billing at Medicare rates	30-60%
Financial Hardship	Document inability to pay full amount	40-100%
Payment Plan	Request interest-free payment plan	N/A (same total, manageable payments)
Lump Sum Offer	Offer reduced lump sum to settle	25-50%

Charity Care and Financial Assistance

Nonprofit hospitals are required to provide financial assistance to qualifying patients:

• IRS requirement: Under IRC 501(r), nonprofit hospitals must have written financial assistance policies
• Eligibility: Typically 200-400% of federal poverty level ($60,000-$120,000 for family of 4)
• Coverage: Can cover 100% of bill for lowest income patients
• Required notice: Hospitals must notify patients of financial assistance before collection

State Medical Billing Laws

Many states have enacted additional protections beyond federal law:

State	Key Protections	Statute
California	Charity care for 400% FPL, no liens on primary residence	Health & Safety Code 127400-127425
New York	Surprise bill protection, emergency services caps	Financial Services Law 603
Texas	Surprise bill mediation for bills over $500	Insurance Code 1467
Colorado	Balance billing ban, 180-day billing deadline	C.R.S. 6-20-102
Florida	Facility fee disclosure, emergency protections	F.S. 395.301
Maryland	All-payer rate regulation, no balance billing	Health-General Article 19-214.2
Illinois	Charity care requirements, collection restrictions	210 ILCS 88/
Massachusetts	Price transparency, interest rate limits	M.G.L. c. 111 §227

Medical Debt Collection Rules

If your medical debt goes to collections, you have important rights:

FDCPA Protections

The Fair Debt Collection Practices Act (15 U.S.C. 1692) applies to medical debt collectors:

• Debt validation: You can request validation within 30 days
• No harassment: Limited calls, no abuse or threats
• No false statements: Cannot misrepresent the debt
• Dispute rights: Must cease collection during dispute

Credit Reporting Changes

Recent changes provide significant protection for medical debt on credit reports:

• One-year delay: Medical debt cannot appear on credit reports until one year after becoming delinquent
• Paid debt removed: Medical debt paid off must be removed from credit reports
• Small debt excluded: Medical debt under $500 cannot be reported (as of 2023)
• Insurance-covered debt: Debt being paid by insurance cannot be reported

Step-by-Step Dispute Process

Follow these steps to dispute a medical bill effectively:

Step 1: Request an Itemized Bill

• Call the billing department and request itemized statement
• Ask for CPT codes for all services
• Request this in writing with receipt confirmation
• Provider must provide within 30 days

Step 2: Request Medical Records

• Submit HIPAA records request
• Compare records to bill
• Look for services billed but not documented
• Note any discrepancies in dates or procedures

Step 3: Compare to Fair Prices

• Use Healthcare Bluebook or FAIR Health to check fair prices
• Look up Medicare reimbursement rates
• Document significant overcharges

Step 4: Submit Written Dispute

• Send dispute letter via certified mail
• Identify specific errors with evidence
• Request bill be corrected within 30 days
• State you are disputing the debt pending investigation

Step 5: Escalate If Necessary

• File complaint with state Attorney General
• Report to state insurance commissioner
• File No Surprises Act complaint with CMS
• Contact hospital patient advocate
• Consider medical billing advocate or attorney

Filing Complaints

If the provider won't resolve your dispute, file complaints with:

Agency	When to File	How to File
CMS No Surprises Help Desk	Surprise billing violations, good faith estimate issues	1-800-985-3059 or cms.gov
State Insurance Commissioner	Insurance claim denials, coverage disputes	Search "state insurance commissioner" + your state
State Attorney General	Billing fraud, deceptive practices	State AG consumer complaint portal
State Medical Board	Provider misconduct, fraudulent billing	State medical board website
CFPB	Medical debt collection violations	consumerfinance.gov/complaint
HHS Office for Civil Rights	HIPAA records access violations	hhs.gov/ocr

Small Claims Court

If negotiation fails, you can sue for medical billing errors in small claims court:

Potential Claims

• Breach of contract: Charged more than agreed price
• Fraud: Intentionally false billing
• Consumer protection violations: Unfair billing practices
• Unjust enrichment: Provider received payment beyond fair value

Damages You May Recover

• Refund of overcharges
• Payments made under protest
• Consequential damages (credit damage, collection costs)
• Statutory damages under consumer protection laws
• Attorney fees in some states

Demand Letter for Medical Billing

Your demand letter should include:

1. Account identification: Patient name, account number, dates of service
2. Specific errors: List each error with evidence (duplicate charges, incorrect codes)
3. Supporting documentation: Itemized bill comparison, medical records
4. Legal basis: Cite No Surprises Act, state laws, FDCPA if applicable
5. Demand: Specific correction requested (remove charges, adjust bill)
6. Deadline: 30 days to respond
7. Consequences: Complaints, legal action if not resolved

Frequently Asked Questions

How long do I have to dispute a medical bill?

There's no federal deadline for disputing medical bills, but act quickly. For insurance claim appeals, you typically have 180 days from denial. For No Surprises Act disputes, you have 120 days from receiving the bill. For charity care applications, many hospitals require applications within 240 days of initial bill. The statute of limitations for legal action varies by state (typically 2-6 years).

Can medical bills affect my credit score?

Medical debt now has greater protections. Medical debt cannot appear on credit reports until one year after becoming delinquent. Paid medical debt must be removed from credit reports. Medical debt under $500 cannot be reported at all. However, unpaid medical debt over $500 that is more than one year delinquent can still appear and negatively impact your score.

What if I can't afford to pay my medical bill?

You have several options: Apply for the hospital's financial assistance (charity care) program, request an interest-free payment plan, ask for a self-pay discount (typically 20-50% off), negotiate a lump sum settlement for less than the full amount, or apply for medical bill assistance programs in your state. Never put medical debt on credit cards as you'll lose many protections.

Can hospitals sue me for unpaid medical bills?

Yes, hospitals and medical providers can sue for unpaid bills, but there are protections. They must typically wait 180 days and make reasonable collection attempts first. Nonprofit hospitals must offer financial assistance before suing. Some states prohibit wage garnishment for medical debt. Many states exempt certain assets from medical debt collection. The hospital cannot sue if the debt is beyond the statute of limitations.

What is the No Surprises Act and how does it protect me?

The No Surprises Act (effective January 2022) protects patients from surprise medical bills. It prohibits balance billing for emergency services (even at out-of-network facilities), for air ambulance services, and for non-emergency services at in-network facilities where an out-of-network provider treats you without your advance consent. For uninsured patients, it requires providers to give good faith estimates before scheduled services.

Should I hire a medical billing advocate?

Consider a billing advocate for complex situations: bills over $5,000, multiple errors across providers, insurance denials involving medical necessity, or if you've been unsuccessful disputing on your own. Advocates typically charge 25-35% of savings achieved or an hourly rate ($75-$200/hour). Many patient advocacy organizations offer free assistance. For smaller bills, self-advocacy using this guide is usually sufficient.

What if the hospital already sent my bill to collections?

You still have rights: Send a debt validation letter within 30 days requesting proof of the debt. The collector must stop collection until validation is provided. Check the statute of limitations - if expired, they cannot sue. Dispute directly with the hospital billing department simultaneously. If errors exist, the debt should be recalled from collections. Report FDCPA violations to the CFPB.