Understanding the Cost of Healthcare: How to Appeal a Claim

A frustrated man and woman sit on a couch while discussing medical bills and deciding whether or not to appeal a claim.
Medical bills are complex, and most Americans don’t understand the actions they can take when they feel their bills are incorrect.

Medical billing in the United States can seem like an extremely complex process. According to a 2016 public opinion survey, nearly 72% of Americans are confused by their medical bills, and 94% have received bills they think are “too expensive”. Even when covered by insurance or Medicare, you may find unexpected balances due to odd procedural codes, medical jargon, and insurance adjustments.

Medical billing processes have many parties involved. There’s you, your insurer, and your healthcare provider. As a result, mistakes can and do happen all the time. A medical coder might have described your medical history with an inaccurate code, a medical biller might have mistyped a number, or a claims adjuster might have applied the wrong plan information to your claim.

Regardless of the reason behind the error, it is important for you as a patient to monitor your bills and EOB statements. If you notice charges that look out of place, do not hesitate to contact your insurers and/or healthcare providers to dispute the error.

How to Identify Billing Errors

  • Compare estimates to your final bill: Before your appointment, contact your healthcare provider and ask to be given the billing code and cost. Next, contact your health insurance provider to make sure the procedure is covered by your plan. Then obtain an estimate of how much you will need to pay for the procedure. If your estimated total is very different from your balance due after the appointment, there may be a billing error.
  • Create a list of charges: Create a record of all the medical services and supplies you received, along with their corresponding charges. This can help you identify an incorrect charge in the future.
  • Duplicate charges: If you notice the same charge listed twice, it is likely that an error occurred during data entry.
  • Beware of upcoding: Upcoding is the criminal act of fraudulently reporting an incorrect diagnosis in order to profit. A disreputable healthcare provider might use upcoding so it receives a large payment from you or your insurance company. If a procedure description or code seems to include services you did not agree to, it could be a form of upcoding.
  • Check identifying information: Make sure your name and identification numbers are correct. Mistakes in identification could lead to insurance coverage discrepancies.

Appealing a Claim Decision

A frustrated man with a laptop lays his head on a table after trying to appeal a claim decision.
Appealing a medical claim decision can be frustrating and tiresome. Knowing the steps to take to be successful will make it easier.

Most health insurers rely on old legacy information systems to review and make claim payments. These systems have been modified repeatedly over the years, so errors often occur. Some experts claim that errors occur in 8% to 10% of resolved claims.

To dispute an insurance company’s claim decision, use the following steps:

  1. Contact the Insurer. Contact the insurance company at the phone number printed on the EOB. If you call, follow up your conversation in writing confirming what you understood and the action that will follow.
  2. Get Names and Contact Information for Anyone You Speak With. Make a note of the name, address, and phone number of anyone you talk with. Use these people’s names to personalize the conversation. It may help them see you as more than just another complaint and make them more willing to help you.
  3. Keep Good Records. Accurate documentation is essential when disputing a claim decision. Never rely on your memory alone. Insurers are generally large bureaucratic organizations with multiple levels of management. A good outcome could require weeks, or even months, to be completely settled. So, make sure to document every step of the process.
  4. Don’t Give Up. Escalate your request to higher-ups if you run into a roadblock, a hostile representative, or a decision you disagree with. A letter to the president of the insurance company and your state’s insurance commissioner will generate activity on your claim, but you should only use it as a last resort.

Above all, remember to not be afraid to ask questions when at the hospital or doctor’s office; it is important to properly grasp what is covered by your insurance. Maintain a record of your medical bills and keep an eye out for errors and discrepancies. In the long run, various errors and honest mistakes are likely to occur. So, keep in mind that the personnel at the insurance company may be just as bewildered as you are. Being angry or belligerent won’t help you achieve the results you want.

Did you find this post helpful? Be sure to read our other guides on how to understand your medical bill and Explanation of Benefits statements.

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