Patient Fairness explores a variety of foundations on which to dispute a medical bill, including the following:
Balance Billing
Does the Medical Bill charge for amounts or services that the provider was supposed to write off according to your insurance plan.
No Surprises Act
Does the Medical Bill and provider’s conduct conform to the federal No Surprises Act. The No Surprises Act (1) requires providers to give patients a good faith estimate of services and costs in advance of services, and (2) prohibits surprise bills whereby the patient doesn’t know to expect a bill or what he or she will be expected to pay.
State laws
Many states have their own laws that offer consumer protections from unfair medical bills. These give an additional layer of defense to patients beyond federal laws and insurance plans, and may include the following:
- Balance billing restrictions beyond the No Surprises Act
- Prohibitions on billing certain charges such as facility fees
- Charge limits for eligible patients (usually income-based qualifications)
- Timeframes providers must follow when billing patients; and
- Limits on medical debt collection tactics (e.g. liens on homes & garnishing wages)
The Medical Bill is Wrong or Inaccurate
The Medical
Bill may not be accurate. Dates, services and other representations by the provider may reflect what the patient received. In some cases, the customer may not have received any services from the provider.
No Agreement or Disclosure on Prices
The provider failed to disclose prices in advance, and the patient and provider never had an agreement on what should be paid for services.
Transparency
The federal Hospital Transparency Rule, and some state laws, require hospitals to provide clear, accessible pricing information online about the items and services they provide. The goal is to make it easier for consumers to shop and compare prices across hospitals and estimate the cost of care before going to the hospital. As many as 70% of hospitals are non-compliant with the Hospital Transparency Rule.
2. Dispute the Bill
Using the information from the Problem Medical Bill Assessment, Patient Fairness creates a Letter of Dispute specifically for your medical bill and its circumstances. The Letter of Dispute is the cornerstone for your challenge to the medical bill with these key functions and notices.
- You present your issues and concerns identified in the Problem Medical Bill Assessment.
- You are formally disputing the medical bill.
- The provider must resolve your concerns for you to withdraw your dispute.
- You will not pay the medical bill while it is under dispute.
- The Letter of Dispute gives the provider 30 days[i] to respond to your issues and concerns. Patient Fairness mails the Letter of Dispute with tracking to confirm the date the provider receives it.
Once the Letter of Dispute is issued, the customer waits for the provider to respond and can then pursue resolution of the medical bill.
3. Pursue Resolution
The stage of pursuing resolution can include a wide range of activity levels, from the dormancy of waiting for the provider to respond to the Letter of Dispute, to the whirl of exchanges of arguments and proposals regarding a settlement between the parties. The degree of activity is largely dependent on the attention and responsiveness from the provider.
The provider may not respond initially to the Letter of Dispute, or even acknowledge it received it. Patient Fairness will send a follow up letter to the provider if it has not replied within 30 days (<30 days if required by state law). Because the Letter of Dispute is the customer’s official record of why he or she is disputing the medical bill, it is important to require the provider to respond to the Letter of Dispute to hold it accountable to address the letter’s concerns. The most effective way to get the provider to respond is to reinforce two key points from the Letter of Dispute every time it tries to collect on the medical bill. (1) The provider must resolve your concerns for you to withdraw your dispute. (2) You will not pay the medical bill while the medical bill is under dispute. See the article “The Provider is Still Billing after my Letter of Dispute” for more on this topic.
By encouraging the provider to respond to the Letter of Dispute by holding fast to the two prior points, the customer is pursuing resolution by encouraging the provider to address the Letter of Dispute’s concerns. The provider understands that the customer is not going to pay the claim without doing so.
It is not uncommon for providers to stop trying to collect on a disputed medical bill without responding to a Letter of Dispute. In these cases, the customer has succeeded in getting the bill rescinded or account written off by the provider, but may not get an official notice as such.
When a provider does respond to a Letter of Dispute, Patient Fairness offers a structured guide to evaluate how well the response addresses the dispute’s concerns, and tools to understand the level of charges and payments in order to consider a proposal and negotiate a settlement.
If the provider and customer agree to a payment amount to settle the dispute, Patient Fairness provides template communications and agreements to document those terms.
At the point that the provider and customer agree to a settlement, or the provider is no longer trying to collect from the customer, the medical dispute case with Patient Fairness is closed.
Closing a Case
A medical bill dispute can end in a variety of ways. The patient and the provider may sign a settlement agreement. The provider may stop trying to collect on, or write off, the bill without informing the patient. The provider may drop the dispute and pay the bill. The patient may drop the dispute and pay the bill.
It is important that a customer let’s Patient Fairness know when a dispute case is closed, and what is the outcome. Patient Fairness will follow up with customers regularly on open cases for which we do not have recent activity to see if the cases should be closed, or there should be other action to try to advance the case towards resolution.
The records of a dispute will remain accessible to the customer on the Patient Fairness site for later reference after the case is closed.
