9 tips to help you negotiate a medical bill

Many patients have been blindsided by unexpected and costly medical bills.

For those who have insurance, there may have been a mistake with pre-authorization. Patients may have been unaware that the anesthesiologist in the operating room was out-of-network with their health insurance plan. Or, in many cases, the health-care provider, hospital or insurance company may have made an error in processing a medical claim.

Each situation - and each medical bill - is different and requires its own approach to solve, said Susan Null, co-owner of Systemedic, a medical billing and patient advocacy organization.

Patient advocates and attorneys who specialize in medical debt offered these tips to save on medical costs.

1. Understand how medical codes work

Medical codes are diagnoses, procedures and treatments that have been assigned a number, turning them into a universal language for those in the health-care industry.

Some medical conditions, particularly those not universally recognized in the medical community, such as chronic Lyme disease, may not have an adequate code for billing, so treatments for them may get denied by insurance companies, said Barbara Abruzzo, a registered nurse and president of the patient advocacy organization Livingwell Care Navigation.

If the reason for the denial is that your insurance does not cover chronic Lyme, for example, ask your doctor about instead using a diagnostic code for other - more widely accepted - conditions related to your Lyme diagnosis, such as joint inflammation, which may be covered, she said.

2. Get pre-authorization for tests, procedures

Before a medical test or procedure - even when the testing center, doctor’s office or hospital tells you that it has been authorized by your health insurance provider - verify it.

Rhonda Orin, an attorney focusing on insurance coverage issues, suggests asking for documentation of the approval - such as a letter or, if it was approved over the phone, a reference number for your records. If you want to take it a step further, you can contact your insurance company and use that reference number to double-check that it was indeed authorized, said Orin, author of “Making Them Pay: How to Get the Most From Health Insurance and Managed Care.”

If your pre-authorization is denied, make sure the doctor who reviewed your case for the insurance company is a specialist in your condition.

For instance, when a patient with Stage 4 kidney disease tries to get approval for a transplant, the case should be reviewed by a nephrologist, a doctor who specializes in kidney issues - not an emergency room doctor, which happens, said Sarah Jane Yang, a registered nurse and medical financial advocate at GreyZone Health. “That is a very strong argument to ask for a second review,” she said.

You can also ask for a peer-to-peer review, which means the doctor reviewing your case for the insurance company speaks with your treating physician to better understand your medical situation.

3. If it was covered in the past, push to get it covered again

A procedure or treatment covered by your insurance company in the past may not be covered now. “Government regulations could have changed. The hospital rate for those services could have changed,” Orin said. But “you should use that as a fact in your favor,” she said.

As long as your insurance policy, the diagnosis and procedure codes are exactly the same, in theory, you should be covered again.

“It might take some phone calls. It might take the insurance company escalating your claim to a case manager,” Yang said. But if the insurance company paid in the past, “they have no rationale not to this time.” she said.

4. Protect yourself from out-of-network costs

The No Surprises Act protects many insured patients from surprise medical bills for out-of-network physicians when circumstances are out of their control.

Patients who receive emergency care or seek certain non-emergency care at a hospital that is in-network but are seen by physicians at that hospital who are out-of-network should be responsible for only in-network rates. The law does not cover people with Medicare, Medicaid or VA health care, for instance, because these entities have their own protections, experts said.

It is not feasible to ask all doctors who enter your hospital room whether they accept your insurance, so Orin suggested proactively sending an email or letter to the hospital’s billing department before a planned medical procedure. In it, state that you do not want any health-care provider who is out-of-network to be involved in your care.

It’s not a guarantee, said Orin, but it could help your case to have documented your wishes in advance. You can say, “You shouldn’t bill me, because I was unconscious on the table, and you did exactly what I said not to do,’” Orin said. “It gives you something to talk about.”

5. Get an itemized bill

An itemized bill should list all procedure codes, which should tell you exactly which services you were charged for, or the description of those services. This is the same information your insurance company uses to determine what is covered under your policy.

Check that you received the services. If not, contact your health-care provider and have them explain any discrepancies, experts said.

Then get your explanation of benefits from your health insurance provider and compare it to the itemized bill. If they do not line up, experts said, ask everyone involved to explain how the numbers were determined.

Simple mistakes such an incorrect medical code or a missing medical record should be easily corrected. “This happens a lot,” said Martine Brousse, a patient advocate who was a billing manager for medical providers before starting her own patient advocacy firm called AdvimedPro.

In general, when negotiating medical bills, experts said, the key is to make a connection with a person who has decision-making power, whether at your physician’s office, hospital or health insurance company. “The systems are cold, but the individuals aren’t,” Yang said.

6. Loop in your health-care provider

If a medical bill problem is going to take time to sort out, Null suggested asking the billing department of your health-care provider to put the claim on hold, explaining that you are disputing the bill with your insurance provider and need time to do it. This will give you that time without the risk of being turned over to a collection agency.

“You want to show the provider that you are taking on the responsibility,” she said. “But you want to make sure that the bill you pay is the appropriate bill to pay.”

7. Consider an appeal

The burden is on the insurance company to explain the costs on your bill, Brousse said. “They have a fiduciary duty toward their members to not only pay the claims properly and at the highest rate possible, but to stand and justify how they process the claim,” she said.

When you still believe there is an error, you can appeal the claim with the insurance company. Brousse cautioned, however, that there is often a limit on the number of appeals - sometimes only two to three - so do not waste an appeal when a simple phone call may get the claim reprocessed.

8. Enlist help from a patient advocate

Once you hit a roadblock or a dead-end, it may be time to contact a professional for help. Patient advocates, also called patient navigators, can be hired to help. Be sure to discuss fees, often based on hourly rates, in advance.

“If you have any kind of underlying suspicion that what the insurance has told you is not right, definitely contact a patient advocate, at least to give yourself peace of mind,” Brousse said.

9. Take advantage of financial assistance

If there was no mistake with your bill, but you cannot afford to pay it, check into financial assistance. Under the Affordable Care Act, hospitals are required to have financial assistance policies. If you meet certain income requirements, you may qualify for financial assistance programs, often called “charity care.” These programs may allow your bill to be canceled in whole or in part.

Every hospital can set its own income requirements - based on the current federal poverty levels - and these should be listed on its website. If not, contact the billing department to get that information, Brousse said.

For hospital bills, a financial counselor or social worker at the facility can help determine whether you may qualify for financial assistance and then help you apply for it.

If you are uninsured, ask for a self-pay or cash discount, Brousse said. If you are not eligible for charity care, set up a payment plan. Get the agreement and any terms related to it in writing to protect against interest surprises, late fees or penalties.

And don’t put it on a credit card or take out a loan to pay for it before you seek assistance, said Berneta Haynes, a senior staff attorney at the National Consumer Law Center. By paying it off, even on credit, “you’re essentially giving up your ability to even obtain financial assistance,” she said.

Don’t take too much time to decide. Health-care providers can - and will - sell your debt to collections agencies after 90 days. It is, however, in their best interest to work with you since they sell that debt at a fraction of the cost, Yang said.