Your medical billing questions, answered

Have you received a medical bill that doesn’t look right? There could be an error. Here’s what you can do about it.

When you get your credit card bill each month, you might examine it closely for errors and unexplained charges. But do you do the same with your medical bills? You might want to start.

It’s hard to know exactly how common medical billing errors are, but Adria Gross says she sees it often in her practice. She’s a medical billing advocate and CEO of MedWise Insurance Advocacy in Monroe, New York. “Unfortunately, you can’t just trust all your medical charges,” she says.

But how can you tell if you’ve been billed incorrectly? Here are answers to some of the most common medical billing questions — and tips for making sure you’re paying the right amount.

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How do I know what my health plan covers?

It’s easy: Read your policy, says Gross. You can review your plan’s Summary of Benefits Coverage. It explains:

What your plan does and doesn’t cover
How much you and your insurer will each pay for care, including deductibles, copays and coinsurance
Any limitations or exclusions to care

While you’re at it, check whether your doctors, hospitals and medications are covered on your plan. Some plans have limited provider networks. You’ll save money if you go to a provider that is in your plan’s network.

You’ll want to review this information every year, as your plan’s details can change from year to year.

If you still have questions about whether your care is covered, call your insurer. They can talk through your specific situation with you. Another option? Find a health insurance plan that covers the medical care you need. Call a licensed insurance agent at 1-844-211-7730.

How do medical bills work?

After you receive treatment from your doctor or another provider, the billing department will send a claim to your insurer, explains Gross. The claim outlines what care you received and what the provider charges for that care.

Your insurer will review the claim and agree to pay their portion based on what they cover and what prices they have negotiated with the provider.

After your insurer has agreed to pay their part, your provider will send you a bill for the remaining amount. You’ll pay that amount directly to the provider’s office.

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What is an Explanation on Benefits, and how is it different from a bill?

In addition to the bill you receive from your provider, you’ll also receive an Explanation of Benefits (EOB) from your insurer.

“It’s not a bill, and it’s important to know how it differs from one,” stresses Gross.

According to Gross, the EOB explains:

What treatments and services your provider has billed you for
What your insurer covers, and how much they will pay (if something is denied, the EOB will explain why)
How much you are responsible for paying to the provider (this amount should be the same as the bill you get from the provider)

You may receive a bill from your provider before you get an EOB. If you do, don’t pay it yet. The EOB is important for double-checking that your medical bill is correct.

“I always advise people not to pay a penny of a medical bill before they’ve gotten an EOB,” says Gross. “If anything is on the bill but not on the EOB, call your provider and have them explain it to you. You need to be sure you are being billed correctly.”

What key things should I pay attention to on my medical bills?

First, make sure the services on your bill were performed. You want to make sure that you’re not paying for care or treatment that you didn’t receive. “This is where most fraudulent bills occur,” says Gross. If you’re not sure if a service was performed, ask your provider to confirm.

Other things to check, especially if you had a medical procedure or were hospitalized, include:

The dates and number of days. The dates on the bill should match when you were in the hospital — or when you had the office visit or procedure.
Number errors. Major billing errors can result from something as simple as a typo. Make sure there are no extra zeros in a number (for example, 2,000 instead of 200).
Double billing. Make sure you weren’t billed twice for anything.
Medicine charges. If you brought your prescription pills from home, make sure the hospital didn’t charge you for them.
Charges for routine supplies. Basic supplies such as gloves, gowns and sheets are usually included in a hospital’s general costs. Talk to your provider if you’re charged separately for things like that.
Care or services you didn’t receive. Make sure that you aren’t being charged for something you didn’t receive. For example, if your provider ordered a test but later canceled it, it could still show up on your bill. If you’re not sure if you received something you’re being charged for, ask your provider to explain.

In addition, make sure that you weren’t “balance billed.” Here’s what that means: On your EOB, for each service, you’ll see “provider charges” and “allowed charges.” The provider charge is what your provider charged for the service. The allowed charge is what your insurer has agreed to pay for the service. “Balance billing” is when your provider charges you the difference between those amounts. If your provider is in your insurer’s network, they are not allowed to balance bill you.

But you can be balance billed if you go out of network. Talk to your insurer if you think you have been wrongfully balance billed.

What can I do to challenge a medical bill?

There are a few reasons why you might want to challenge a bill, says Gross. They include:

Duplicate charges. Make sure you aren’t being charged more than once for the same service or treatment.
Balance billing for an in-network provider.
Your hospital didn’t charge a fair price. If you had surgery or another procedure, you can check websites, such as Healthcare Bluebook and FAIR Health, to find out what a fair price for that procedure is in your area. Enter the name of your procedure and your zip code to find the average price. If the charge on your bill is higher than the fair price, you can try negotiating a lower fee.
You were wrongly charged for out-of-network care. Thanks to the No Surprises Act, a law that’s been in effect since January 2022, you can’t be charged more for out-of-network care if:
- You received emergency care from an out-of-network hospital.
- You received care from an out-of-network provider at an in-network facility. For example, if you had surgery at an in-network facility, but the anesthesiologist was not in the network.

If you suspect you’ve been billed incorrectly, the first step is to discuss your bill with your provider, advises Gross. If they can’t fix the problem, talk to your insurance company, too.

If that doesn’t get you anywhere, you can also file a complaint online with the Centers for Medicare & Medicaid Services or call the No Surprises Help Desk at 1-800-985-3059.

What can I do if I can’t afford to pay my bill?

If you’re struggling to pay your medical bills, you have a few options. Talk to your provider’s billing department. They may have financial counselors that can help.

Try negotiating your bill. The billing department may be willing to settle on an amount that you can pay.
Ask for a payment plan. Many providers offer payment plans where you can pay off your bill in installments over time. These are often interest-free if you pay within a certain time period.
Apply for financial assistance. . Nonprofit hospitals are required to offer “charity care” under the Affordable Care Act. This is free or discounted care for people with low incomes.

A licensed insurance agent can help you shop for a health insurance plan with in-network doctors who can help lower your out-of-pocket costs. Call one today at 1-844-211-7730 or enter your zip code to browse available plans.

Sources

Consumer Financial Protection Bureau. “Is there financial help for my medical bills?” June 10, 2022. Retrieved from https://www.consumerfinance.gov/ask-cfpb/is-there-financial-help-for-my-medical-bills-en-2124/

Consumer Financial Protection Bureau. “What is a ‘surprise medical bill’ and what should I know about the No Surprises Act?” February 2, 2022. Retrieved from https://www.consumerfinance.gov/ask-cfpb/what-is-a-surprise-medical-bill-and-what-should-i-know-about-the-no-surprises-act-en-2123/

Consumer Financial Protection Bureau. “What should I know about medical credit cards and payment plans for medical bills?” February 2, 2023. Retrieved from https://www.consumerfinance.gov/ask-cfpb/what-should-i-know-about-medical-credit-cards-and-payment-plans-for-medical-bills-en-1827/

HealthCare.gov. “Balance billing.” Retrieved from https://www.healthcare.gov/glossary/balance-billing/ Accessed April 18, 2023.

MedlinePlus. “Understanding your medical bill.” August 11, 2022. Retrieved from https://medlineplus.gov/ency/patientinstructions/000881.htm

U.S. Department of Health and Human Services. “Reading your explanation of benefits (EOB).” May 2022. Retrieved from https://www.cms.gov/files/document/11819-sample-explanation-benefits-508.pdf

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