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What should I do if I receive a bill directly from a doctor, hospital, lab, imaging center, or other diagnostic service provider?

If you receive a bill directly from a doctor, hospital, or diagnostic service provider, do not immediately pay it since it will likely have only the Provider Charges from that provider’s Charge Master, and those prices do NOT reflect the reasonable amount due. Instead, call the diagnostic service provider’s customer service line, make sure they have your insurance information, and ask them to submit the bill to your insurance company.  They should do this as a matter of course if they are in network for your insurance plan, but ask them to do it regardless.  If they do, terrific.

If they refuse, make your next call to your insurance company and ask if they’ll process the bill if you send it to them, which they should. If they do, terrific.

If they refuse, and/or if the provider is out of network for your plan, ask your insurance company if they’ll give you reasonable and customary rates for your itemized services.

Next, review the bill carefully and look for errors.  For outpatient providers, see Step 9 under Estimating costs for Outpatient Visits.  For inpatient providers, see Step 14 under Estimating costs for Inpatient Stays.  For both, note that you’re resolving a direct bill (instead of an EOB from your insurance plan), and also note that the downloadable checklists have more detail.

Once any billing errors have been corrected (ie removed from your bill), negotiate a mutually acceptable number to settle on.  Apply some Pricing Tools to get a sense of reasonable and customary rates in your area.  If that doesn’t help, make sure that the person you’re negotiating with understands that you know how inflated the typical Provider Charges are, and put up an opening bid of 20% of the total due.



Next:  Everyone’s favorite topic; how to read your Explanation of Benefits!  Yeee haaa!


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