If you’ve received an excessive or surprise medical bill over $5,000, it might be necessary to conduct a medical claims audit to ensure you were charged fairly for the services. Sometimes, medical bills get processed incorrectly and mistakes could have been made either by the provider or the insurance company.

What Should I Do if I Get a Surprise Medical Bill Over $5,000?

Rather than make assumptions about what might have happened to result in such a large bill, it may be time to get help from a medical bill advocate who knows how to dispute large medical bills. They can help to uncover any problems that occurred in the billing process during a medical bill audit.

While you should never ignore a medical bill, you also shouldn’t pay it until you know it’s correct — this is where a medical bill audit comes in and can ensure you’re not paying more than you should. The larger the bill, the more important it is for you to have it audited to protect your rights. Here’s an overview of what happens during the medical claims audit process:

1.     Request a Detailed and Itemized Statement from the Provider

The first step in a medical bill audit is requesting and analyzing an itemized statement from the medical provider. A detailed and itemized statement breaks down the individual charges line by line, more specifically than in the EOB. For example, rather than just showing “radiology,” it will list each individual scan and lab charge under the umbrella category, showing each item that makes up the total on your bill.

Carefully going through an itemized statement is critical to ensure you don’t pay for a service you didn’t receive. Since this is not information a hospital might readily provide, obtaining a copy of your itemized statement might require some persistence.

2.     Review Every Code and Line Item with the Insurance Company

After determining that you received the medical services listed in the itemized statement, it’s necessary to have a conversation with the insurance company and go through each code and line item with them.

During this step of the medical bill audit process, the contracted rate for each line item and how much you’re responsible for is verified under the terms of your particular policy. The medical bill advocate will then take your detailed and itemized bill, compare it to the EOB, and scrutinize each item according to how it’s designated in your plan to find any discrepancies in the documents. If you’ve had extensive treatment, this part of the process can be highly detailed, time-consuming, and complex.

Depending on whether you have a deductible you haven’t met — or coinsurance — you may end up being responsible for all, part, or none of the contracted rate. During this step of the medical bill audit process, the correct balance is determined to ensure you’re only paying in accordance with what you are responsible for under your health plan.

3.     Identify and Resolve Mistakes

The initial claims evaluation can determine whether a medical bill is correct and should be paid or if there are mistakes that need to be resolved. If errors are found, it’s essential to determine where they occurred and precisely what they were. For example:

  • Was a benefit you’re entitled to not applied?
  • Did the provider err in billing?
  • Did the insurance company miscalculate the services?

Resolving a medical bill error either with the provider or the insurance company can involve many factors. For instance, your verbal story as a patient is compared to the written coding and processing of the claim to see how it translated. An experienced medical bill advocate can assess which party is at fault and develop a strategy to resolve the error.

The process to determine whether billing or processing mistakes were made is very nuanced and pulls all the facts together to determine whether there’s a case for an excessive or unfair bill. Depending on what grounds your claim is based on, a medical bill advocate can help determine what it will take to win your case and what kind of documentation is needed to get it resolved.

How Systemedic Can Help With a Medical Bill Audit

If you’ve received an excessive medical bill for treatment of over $5,000, an experienced medical bill dispute advocate can help. An advocate will know how to conduct an effective medical claims audit to determine whether the bill is correct and develop an effective strategy to proceed forward with your case.

Systemedic has been providing help with medical bills for over 30 years and knows what it takes to negotiate out-of-network medical bills quickly and effectively. Offering a fee-based service for those looking to dispute their medical bills, our medical bill dispute advocates are skilled in navigating the insurance maze and will not take “no” for an answer. Contact us for a consultation.