When it comes to fighting medical bills, consumers are at a disadvantage because regulatory oversight of health insurance is split between federal and state agencies. Some states have passed laws that limit hidden fees and prohibit out-of-network providers from charging you the difference between their fees and the reimbursement amount, a practice known as bill balancing Medical Billing Services. But most states don't have those protections. As a result, consumers are often confused about their options and don't know where to turn for help.

That's why Consumer Reports supports the Patient's Bill of Financial Rights that would create a fairer medical billing process (see " Our Position: Patient's Bill of Financial Rights ").”Consumers need simpler and more accurate medical bills that are consolidated and not sent until the insurers have made payments to providers," says Betsy Imholz, director of special projects at Consumers Union, Consumer Reports' advocacy division. .

There is no foolproof way to avoid medical billing errors, but there are many things you can do to minimize the likelihood of problems. "It's important that you take advantage of whatever strategy you can," says Carolyn McClanahan, MD, a certified financial planner in Jacksonville, Florida. So before you go to a doctor (and after you start getting the bills), follow these steps.

Many billing problems start because people don't understand the basics of their insurance, including deductible expenses, coverage limits, and provider network. “People think they know what insurance they have, but often they don't. To be fair, insurance changes from year to year. It's complicated, ”says Martha Bradt, a medical claims defense attorney in Rye, New York.

Make sure your provider has the correct insurance information entered into their system. "Many people don't tell their doctor if they have changed jobs or received a new card or if there is a secondary payer," says Cindi Gatton, a private patient attorney in Atlanta.

Smart move: have a cup of coffee and read your health insurance document, which is usually available on the benefits website of your insurer or employer. You will know what your insurance covers and what it does not cover, as well as the limits for the treatments; for example, they allow you up to 20 physical therapy visits per year.

The best way to avoid exorbitant bills is to make sure your providers are in your network, says McClanahan. Don't trust the insurance directory because those listings may be out of date. Call the doctor's office and provide your insurance name and group number to confirm that the doctor is in your network. Also check which hospitals in the area accept you’re insurance.

With an out-of-network provider, they might charge you more because the insurer will reimburse your visit at a lower rate than with a network provider.

Smart move: If you walk into the hospital and are asked to sign a financial responsibility document, write that you agree only if your care is in-network, says Elisabeth Rosenthal, MD, author of "An American Sickness." 2018) and editor-in-chief of Kaiser Health News. That, at the very least, will give you a basis to dispute the bills later if they charge you out-of-network fees.

It's easier to avoid billing surprises if you can determine your charges in advance. In the Consumer Reports survey, only 4 out of 10 people tried to find out what the cost would be before the office visit.

That said, it may not be easy to figure out the prices, but it's worth a try because the cost difference can be huge. That's what Marcy Neely, of Cedar Lake, Indiana, discovered after she was charged more than $ 1,500 for a blood test at a local hospital. When the test had to be repeated, needy, a 45-year-old stay-at-home mom, asked an office worker what to do. They referred her to a lab that only charged $ 270.

To check prices for your area, start with your health insurance website. Most of the major insurers offer online tools that show how much you should owe for common procedures and doctor visits based on your deductible status and insurance features. You can also ask your doctor how much a treatment or procedure might cost you, as well as call local providers to see how their prices compare.

Smart move - Check out  online resources like  FAIR Health ,  Clear Health Costs  or  Healthcare Bluebook that can help you determine prices in your area. This information can be useful if you end up negotiating with a provider (more on this in step 6) because you will know how much providers typically charge for that treatment or service.

“Some providers send bills before insurance processes them, followed by more prompts,” says Arthur Abbie Leibowitz, MD, medical director of Health Advocate Solutions, an employer benefits company. "It is so confusing that many people pay what they do not owe, while others wait too long after receiving a delayed notification."

To make sure you pay what you actually owe, wait until your insurer provides you with an explanation of benefits (EOB) for that date of service. Find out what insurance paid and how much you are entitled to, says Leibowitz. At that point, you will receive another invoice from the provider that reflects the insurance payment and the amount you owe. The two quantities must be equal. So you will know what you really owe.

Smart move: Make it a habit to keep your health care records, including receipts, statements, and EOBs organized. And if you have to call, keep a record of the people you spoke to and ask for a reference number.

If you get a medical bill that appears to be incorrect, call the provider and your insurer and explain why the bill appears to be incorrect. Maybe the doctor just entered the wrong code or the insurer didn't get the bill. If so, ask the provider to resubmit the claim with the necessary corrections. "A lot of problems can be cleared up with a couple of phone calls," says Gatton.

If that doesn't work, try to diagnose the problem and find out who can fix it. Maybe your health insurer says it doesn't cover a treatment, but your doctor says it should. If so, you may need to gather documentation to strengthen your case. "Your provider most likely wants to help you because they want to get paid," says Cyndee Weston, CEO of the American Medical Billing Association, a trade group.

Note that most providers set a 60-90 day time limit for bill payment, so if there is a dispute, notify the billing office in writing. They can freeze the account for 30 more days. Otherwise, your account could be sent to collections. You also face a time limit for appealing denials to your insurance company, which can range from 90 to 180 days, says Martine Brousse, a medical billing patient advocate in Culver City, California.

Smart move: If your efforts are getting you nowhere, it may be time to seek help. You can start with your employer's benefits department. About 64% of large companies offer patient advocacy help, according to a 2018 survey by the National Business Group on Health, a nonprofit organization. For other options, see “How to get help with your bills.”

Sometimes trying to negotiate is a better alternative than a lengthy billing battle. If you have enough cash on hand, consider offering to pay most of the bill right away. "You can often get the provider to accept a payment that is 20% or more off if you pay them right away," says Bonnie Sheeren, a Houston medical billing defense attorney. As noted in step 3, having information about which provider’s insurance companies or Medicare typically pay can help strengthen your case.

If your income is low, another option is to request a reduced rate based on financial hardship. That strategy worked for Marc and Anne Montgomery of Covington, Georgia. Last October Marc, a 40-year-old carpenter, needed outpatient surgery for a hernia.

The couple had short-term health insurance through Meritain, who pre-authorized the procedure. But the claim, which amounted to $ 30,000, was later denied because it was deemed not medically necessary. "We were shocked because the surgery had a pre-authorization," says 33-year-old Anne, a market researcher. (Meritain declined to comment on the Montgomery case for this article.)

Pre-authorization from an insurer does not guarantee that claims will be covered. The couple fought denial but got nowhere. Then, in January, Anne contacted a medical billing defense attorney, who advised her to seek financial assistance from the hospital based on her low income. "When I told the hospital billing department that the bills would cause significant financial hardship, that opened the doors," says Anne. In February, the hospital waived his bill, prompting most other medical providers to cancel the charges. The couple now have insurance from the Health Insurance Marketplace.

Smart move:  When negotiating, try to speak to someone in authority to reach an agreement, such as a supervisor or the head of the billing department. Getting to the right person can take a lot of persistence, but sometimes it's the only way to end a medical billing problem.