Medical Bill Looks Too High? Six Things to Check First

Match the bill to the Explanation of Benefits

The bill comes from the provider. The EOB (explanation of benefits) comes from the insurance company, and it is the summary that shows how your plan handled the claim. The two documents are related, but they are not the same document, so you want to read them side by side.

Start by matching the following fields between the bill and the EOB:

• Service date
• Provider name
• Claim number
• Patient responsibility
• Insurance payment
• Deductible, copay, and coinsurance
• Adjustment amount

If the provider bill asks for more than the EOB says you owe, write that difference down before you call billing. If the claim was denied, save the denial notice. HealthCare.gov says internal appeals are generally due within 180 days after receiving the denial notice, and that date matters more than the date you finally open the bill.

Check whether the provider was in network

Network status affects the amount you owe. An in-network provider has a contract with the insurance plan, which means the plan pays a negotiated rate (the discounted price the plan and the provider agreed on in advance). An out-of-network provider has no such contract and may charge more, unless a consumer protection rule applies.

Check the bill, the EOB, and the provider portal for both the provider name and the facility name. A hospital can be in network while a separate doctor, lab, anesthesiologist, or imaging provider bills you separately, so the network status is not always the same across a single visit.

CMS says the No Surprises Act protects covered patients from certain surprise bills tied to:

• Emergency care
• Certain out-of-network care at in-network facilities
• Out-of-network air ambulance services

If the bill appears tied to one of those categories, save the bill and review the plan instructions before you pay.

Ask for the itemized bill

A summary bill can show one total. An itemized bill (a statement that breaks the visit into individual charges) shows you what each of those charges is for.

Ask the provider billing office for an itemized statement that includes:

• The service date
• Charge descriptions
• Billing codes, if available
• Unit counts
• Payments and adjustments
• The remaining balance

Use the account number from the bill so the office pulls the correct record. After the itemized bill arrives, compare the line items to what happened during the visit.

As you compare, look for:

• Duplicate charges
• Dates that do not match
• Services that were canceled
• Supplies that seem repeated
• Charges that should have gone through insurance first

Look for insurance processing problems

A bill can be high because insurance did not process the claim correctly. Common issues include:

• Old insurance information
• Missing prior authorization
• Wrong member ID
• Wrong provider network status
• Wrong claim code
• A claim that was sent to the wrong plan

Call the insurer with the claim number from the EOB, and ask:

• What reason code was used
• Whether the provider can resubmit the claim
• Whether the denial can be appealed
• Where the written appeal instructions are listed

Write down the date, the representative name, the call reference number, and the next step given by the insurer, and keep those notes with the bill and the EOB.

Check whether financial assistance applies

Financial assistance is a hospital program that lowers or forgives a bill for patients who qualify, usually based on income. If the bill came from a nonprofit hospital, ask for the hospital financial assistance policy. The IRS says tax-exempt hospitals must have a written financial assistance policy that explains who may qualify and how to apply.

Financial assistance can be separate from an insurance appeal, so one bill can be reviewed for insurance errors and also screened for hospital assistance at the same time. Ask billing whether the account can be paused while an assistance application is reviewed.

Save a copy of everything you send and receive, including:

• The application
• Proof of income
• The submission date
• Any letter the hospital sends back

Do not rely on one phone call

A phone call can help, but written proof matters more. Ask for a written copy of any:

• Billing correction
• Payment hold
• Insurance resubmission
• Financial assistance review
• Appeal instruction

Create a call log, and for each call track:

• The date
• The office you called
• The phone number
• The representative name
• The reference number
• What was said and what is supposed to happen next

If the bill is being reviewed, ask when follow-up is expected and whether collection activity is paused during the review.