How to Deal with Unexpected Medical Bills

By Kevin Brasler, Consumers’ Checkbook 

“This must be a mistake.” 

That’s a common reaction to notices sent by healthcare providers and insurers. And sometimes it is a mistake. It might be an error, or your insurer hasn’t paid the claim yet. Or the provider submitted the claim but used the wrong codes. Or your insurance plan decided it doesn’t have to cover the care you got. Or you’ve discovered, too late, a coverage gap in your insurance, or forgotten about your plan’s annual deductible. 

Unfortunately, accurate bills can pile up from major medical needs—medical debt is the cause of one in five bankruptcies. 

Although it’s a complicated system, here’s how to deal with surprise-bill nightmares. 

Is it really a bill? 

It might just be an Explanation of Benefits (EOB) sent by your insurer that reports the sometimes-shocking prices of services you received. These notices can be confusing and usually include costs you don’t pay. Zero in on the bottom-line “patient responsibility” amount. 

What’s your deductible? 

Many insurance plans now come with annual deductibles of $1,000 or more. That’s the amount you pay out of pocket before benefits kick in. This often explains surprise bills, especially right after policy renewal time. 

Give the system time to sort itself out. 

Procrastinators rejoice: By waiting a month or so, you give healthcare providers time to submit claims and for reimbursement to occur. 

Make sure the provider billed your insurer. 

Check the bill for adjustments and payments from your insurer. If you don’t see any, ask the provider’s office staff if a claim was submitted; if one wasn’t sent, ask them to do so promptly. If it appears a billing mistake was made, ask them to fix it and resubmit. 

If the provider doesn’t participate in your insurance plan’s network, they might not submit your claims at all, even if you ask. In that case, you must do that—and likely get reimbursed for less than the amount on the bill. If that happens, ask the provider if it will charge you a lower amount, or accept what your insurer pays as full payment. 

Check that your health insurance plan paid what it should have. 

Get an EOB from your insurer. Compare the info on it with the cost-sharing details of your plan: your annual deductibles (per covered person and per family), copays (which sometimes differ by type of provider), and out-of-pocket limits. Often, a call or email to your insurer or healthcare providers will help you understand the bill. 

If the EOB seems wrong, find out if the healthcare provider made a mistake. 

Also request itemized bills and check them: They often contain errors. 

Compare your detailed bill with your records and what you remember about your diagnosis and treatment. Doctors and hospitals have records, too, and you have a right to obtain copies of them. Ask for any “clinical notes,” “after-visit summaries,” and “patient notes” if you had an ER visit. If you find a discrepancy, ask for an explanation. 

Check whether the bill is illegal. 

If your bill was for medical care you didn’t foresee—an accident, sudden illness, or other emergency—the federal No Surprises Act, which went into effect in 2022, provides protections if you were treated at a hospital ER that participates in your insurance plan’s provider network. The law stipulates that any out-of-network providers working there cannot bill you for amounts above your insurer’s in-network rate. 

Such so-called “balance billing” often added hundreds to thousands of dollars in surprise medical charges to the costs of ER visits. 

Seek help with expensive prescriptions. 

Need an expensive drug not covered by your insurance plan? Check with the pharmaceutical manufacturer to see if it has a patient support program offering significantly reduced prices for qualified applicants. Doctors and their staff often know about these programs, too. In some cases, you might first have to show that you unsuccessfully tried other treatments first. 

Consider hiring a patient advocate. 

If you don’t have the expertise or strength of health to deal with a medical bill, hire a patient advocate. Skilled medical-billing advocates use their knowledge and noses for nonsense to identify errors and apply little-known consumer protection laws to get them fixed. Their expertise and contacts enable them to get fast results that can reduce your financial exposure and alleviate needless stress. Because you usually have to pay patient advocates (costs range from $100 to $350 per hour), hire one only for large bills. 

Ask for a payment plan. 

Providers typically will arrange to let you pay their bills over time, often without interest. Because doctors and hospitals would rather get paid than hand off your debt to a collections service, make sure you adjust the terms of repayment to an amount you can afford.  

About Consumers' Checkbook 

Consumers’ Checkbook is a nonprofit organization with a mission to educate consumers and help them make smarter choices. It offers advice, price comparisons, and in select markets, unbiased ratings of local service providers. It is supported by consumers and takes no money from the companies it evaluates. You can learn more about Checkbook and keep up with its latest reports by visiting Checkbook.org/VeteranSaves.