When you receive medical care, you often receive a quoted price. It’s just an estimate and the bill can differ, but if the final bill is $400 above the good-faith estimate, you may be able to dispute it.
There are strict eligibility rules for uninsured and self-pay patients that determine their ability to challenge a bill, and deadlines to note. Here’s what to know.
Who can dispute a bill under the $400 rule?
Under the No Surprises Act, which went into effect in 2022, a patient can dispute a bill if final bill was at least $400 higher than the provider’s or facility’s estimated charge. Disputes under this rule are typically for uninsured patients or people who did not have insurance for a particular treatment. Insured patients with out-of-network bills have a different disputation method.
A patient must demonstrate that they received a written good-faith estimate before the scheduled service and file a dispute within 120 days (four months).
The Centers for Medicare & Medicaid Services (CMS) notes that you will not receive an estimate for emergency care services. However, you can get a good-faith estimate when care is scheduled at least three business days ahead or if you ask for one.
How to start the dispute process
You will need the final bill, estimate and the provider’s contact information to initiate a dispute. You can file online via the CMS website. You can continue to negotiate with your provider after filing a dispute, and it will not affect your total medical costs.
There is a $25 non-refundable administrative fee for processing the dispute. “If the dispute is decided in your favor, the $25 will be deducted from the amount you owe your provider,” per the CMS.
After you submit your dispute, an independent dispute-resolution entity will review the documents and determine the appropriate payment.
What to expect from the review
A provider cannot send bills to collections, add late fees, threaten collections or initiate any other retaliatory actions against the patient during a dispute. Debt collectors cannot pursue the debt either as it is being negotiated.
Filing a dispute can give you some breathing room before repayment resumes, but you are not guaranteed to win your case. A reviewer may uphold additional costs that came from medical necessity or reasonably unexpected services.
If you are insured and received an unexpected out-of-network bill, you may need to contact your insurer and file a No Surprises Act complaint. In some cases, challenging improper debt collection activity is the better option. Requesting an itemized bill review and directly negotiating with your provider are also options, and some hospitals have financial assistance available.
