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How To Dispute a Medical Bill

making sure medical bills are correct and how to dispute them if necessaryWith the Affordable Care Act came many changes to covered medical services and access to care. While there are a million different opinions about the ACA or Obamacare, I think we can all agree that health care has not gotten any easier to understand. I work in health care and get surprised almost every week by some new twist in insurance billing and coverage. It’s important as a consumer to understand your insurance policy and know how to dispute a medical bill if errors were made. I got a refresher course recently when I had a doctor visit billed incorrectly, so I though I’d share my experience.

What Is Covered with the ACA?

If you have an ACA compliant plan (if you don’t, it probably got cancelled), there are several medical services that are covered without copays, co-insurance, or deductibles if you use a network provider. This applies to any policy, regardless of deductible. Some of these include:

An Annual Physical- Includes screening tests appropriate for your age and risk factors, like mammograms, PSA tests, or diabetes and high blood pressure screenings.


Well Child Visits

You can read the entire list at Healthcare.gov

My “Free” Physical

I went for my annual physical in April. I don’t take any chronic medicines other than birth control. This appointment was mainly to renew that. The doctor asked about labs for cholesterol and triglyceride screenings, and I told her I would be doing those at the upcoming health fair. All of this fits into the definition of routine physical.

At the end of the exam, I brought up an issue I’d been having. I’m a bit embarrassed to say that after a really turbulent flight last year, I now experience anxiety when flying. It’s not crippling. I haven’t needed a straight jacket,  but it can be uncomfortable, especially with a 7 year old to watch over. I knew we would be flying the following month and I wanted her opinion on what I might be able to do on my own or with drugs. I know lots of people take Xanax for flights, but I wasn’t sure that was a route I wanted to take.

We had maybe a 5 minute discussion and ultimately I decided to wait it out. My anxiety seems to lessen with every flight, so I didn’t want to dope myself up and take the chance I’d be incoherent.

The Bill

I was surprised to get a bill this month instead of a remittance from my insurance that said they had paid for my annual physical. When I called to ask the billing department, the clerk said that the visit had been coded as Other Unspecified Phobia and was charged as an office visit. It said I owed $124 because the bill had been applied to my deductible.

How To Dispute a Medical Bill

The most important thing you can do as a medical consumer is know your insurance policy. If you don’t understand, search online. There are a million websites that can explain co-pays, co-insurance, deductibles, HSA’s, flex plans, etc. If your plan is through an employer, the HR person should be able to explain your policy. If they don’t know, ask to speak to their supervisor. Because it’s complicated is not an excuse not to know how to find answers.

I know that the purpose of this visit was my annual physical and the phobia was a secondary diagnosis that came up. I asked the billing clerk to review the claim. After transferring me to another “specialist”, I was told that they had billed the code that was sent and I needed to talk to the nurse who worked with my doctor.

It’s important to follow the steps and be polite. Yelling at a person because she billed what was sent does no good. Billing specialists have no authority to change medical records. The error was not her fault. It was also not the fault of my insurance company. They were correct not to pay based on how this claim was billed.

I then called the nurse as I was instructed to do. I explained what had happend, and her exact quote was, “I have no idea how that stuff works.” I thought that was extremely unprofessional, but I stayed polite and asked if there was someone there who might know how to correct this claim. She then got a bit huffy but said she would ask the doctor. I got a call back a few hours later that the visit had been recoded as a physical and would be rebilled.

If you know you are right, keep asking to speak with an office manager or even the doctor if staff gives you the runaround. Odds are the doctor is not going to take your call, but most of them know how the system works and are happy to fix a billing error. Everyone likes to get paid, and correct billing speeds that along. Staff are usually instructed not to bother the boss with non-medical related issues, so if you start asking to speak to the person in charge and don’t roll over if their explanation doesn’t make sense, things tend to happen faster.

Make Sure You Are Only Getting Preventative Services

It is not preventative care if you’ve been having headaches or chest pains and call to schedule your physical so you won’t have to pay to be seen for these problems. There is a list of elements the doctor must preform to bill for a service, and the code must match the chief complaint. If a routine visit is billed, it must have a routine diagnosis, like well child exam. If an office visit is billed, it must have a medical code, like headache, and is subject to deductible. If a routine visit it billed with medical code, it will be denied altogether.

At the same time you need to discuss problems you’ve been having, even if it is during a routine physical. If you are unsure how to proceed, call your doctor office and ask. If you haven’t been in in years, they might suggest a physical. If a problem is found, you’ll need to come back to address that. You can always ask your doctor during the visit as well. In my case, I probably should have said something like, “I know I’m here for my physical, but is this a good time to bring up another problem I’ve been having?”

Your doctor can tell you whether you should schedule another visit or not. It also never hurts to tell the nurse or tech that you are mainly here for a physical. The chief complaint is always recorded, so make sure you don’t start out by saying you’ve been having bad athlete’s foot or something benign, because that will go in your record. You can bring it up later if you feel it’s necessary, just don’t start out that way.

Be Nice

I can’t stress enough how important it is to be nice. If you don’t understand, ask. If the explanation doesn’t make sense, tell that to whoever is explaining. If you yell, swear, and threaten, people are less likely to help. If you believe you have a claim that was billed incorrectly and you’ve exhausted all options and no one will help, there  are companies that specialize in auditing medical bills. This will cost money, but if you have a huge medical bill that you feel is incorrect, it might be worthwhile.

Insurance is confusing, but that is not a problem that is going away anytime soon. It’s your responsibility to try and understand it as best you can and ask questions if you don’t. It could make a huge difference when it comes to medical bills.

Have you ever had to dispute a medical bill? Do you think having a “phobia” in my record willl come back to haunt me?


Image: Freedigitalphotos.net/Miles

About Kim Parr

Kim Parr is a private practice optometrist, freelance writer, and personal financial blogger. You can follow her journey to 20/20 financial vision at Eyes on the Dollar.


  1. Side topic – But I also have issues when it comes to flying. Like you, the more I do it the less worried I become, but it is something that I try to avoid.

    • I have way too many places I want to see to let fear of flight restrict me. I have to make it to Australia some day! I hope it goes away altogether at some point. I’ve read a ton about turbulence in the last year and understand it better, so that helps. We flew a few weeks ago and had some turbulence, but I was able stay calm.

  2. We’ve had this happen in the past and is usually no problem to get fixed, but we have had an issue or two in the past where it becomes a hassle. Interestingly enough we’ve had issues with having stuff for my son who is named after me coded for me and it causes a major headache. Because it makes sense that I’d be going in for a well baby check up. 😉

    • I would honestly like to see that one go to court or something and they could call you in to give evidence why you didn’t get a well baby check!!!

  3. The medical system is so complicated!!! I have gone to a cheap high deductible plan and pay for all/any visits with an HSA debit card. It allows me to negotiate cash prices up front with the doctor. I’ve had so many issues with insurance companies when I was paying $450/mth for the “good” insurance.

    • I have a very high deductible plan as well and would probably do the same if I had to have a procedure done that would go to the deductible. I knew this was a covered service, so that’s why I wanted to make sure it was done correctly.

  4. Wow, what a story. I wonder if the doctor billed it as that because she would make more money that way? You did talk about the fear, but it should have been a preventative care visit. I’ve never had to dispute a medical bill. Then again, I haven’t really dug into them. I should start doing that!

    • No, I’ve seen my doctor for years and I’m sure she just put in in the record. When you use electronic records software, the last thing she put in might have come up first in the diagnosis section, so that was what got sent to billing. Luckily, I have in house billing, and I do my own coding, so we generally catch things like that before they go out to insurance. If you only do one part and then it gets sent up the food chain, it’s easy for mistakes to happen.

  5. I hate when something like this happens! I had a doctor add a stress related diagnosis to my report a few years ago, but that was so that my insurance company would pay for another test that I needed. I really hate having to figure out the medical billing process. I do, though, thoroughly review all of our bills specifically because you never know how the office is coding your visit and mistakes can really add up.

    • In the whole scheme of things, $124 would not be a huge medical bill. If I wasn’t aware of the rules, I probably would have paid it. I’m sure there are lots of people who do just that or end up not paying and get sent to collections.

  6. Just this past month I have been disputing a very large medical bill for a service that my insurance confirmed would be covered 100% prior to my receiving the service. After five months of back and forth between my provider and insurance, I was notified of the denial when a letter was sent to me. It was then a two week process of getting the insurance company to review the phone log and see what had been communicated. What aggravated me the most was being told that the huge bill (had I been deemed responsible) would not even count toward my deductible or out-of-pocket which I do not totally understand and need to research further. My advice is to also be polite but be persistent. I called probably 10 reps until I spoke with someone who was truly helpful.

    • Wow. I’d like to say I’m surprised, but insurance companies tell people things are covered all the time, and they probably are if you use the right provider and the provider bills the service like the insurance wants them to. Was it a network provider that you saw? I can’t imagine why it wouldn’t at least apply to a deductible otherwise. I wish there was more transparency all the way around.

  7. I went through this hassle once when I went into a routine physical and she asked me if anything else was going on and I mentioned how I had on a couple occasions has those weird ocular migraines (basically seeing lightning flashes) and she gave me a sample of a migraine med which i never used. Later it came up that I had a “pre-exisisting condition” of migraines. WTF? I took over a year and a heavy dose of patience to get that cleared off my bill as it was super expensive. It makes me really paranoid now about what I say and don’t say at the doctors office. I will email you about something going on right now and get your opinion about how I should handle it!

    • I know how you feel. I am very reluctant to get labeled with any diagnosis because I’m on private insurance. I know they can’t cancel me now with the new laws, but who knows if that might change depending on who gets elected in Washington.

  8. I spent 5 months trying to get a $600+ error corrected. I had a routine test come back abnormal, so it was sent out for further testing. My doctor’s office accidentally coded the follow-up testing as routine, so that’s how the lab billed it. The insurance company denied it, because the tests weren’t routine, they were diagnostic. I made a lot of phone calls between the insurance company, the lab, and the doctor’s office before it was finally straightened out.

    I also learned last year that my insurance company has a rule that injuries must be seen within 72 hours, or they decrease the coverage. I had sprained my ankle, and thought I’d be fine just taking it easy for a few days. A week later I finally went to the doctor. The EOB’s from my insurance showed a variety of denial codes. I called the insurance company, and was informed of the 72 hour policy. It ended up costing me $350 more for waiting. Ouch!

    • Wow, that 72 hour rule is one I didn’t know about. That almost sounds like workman’s comp type rules. I need to check my policy and see if that applies there. I’m glad you stuck with the other bill and got it corrected. Most people just give up.

      • I’ve never heard of it with any other insurance, and I actually haven’t found it in writing anywhere in my insurance. But then, our company self-insures, using Anthem as a processor and for catastrophic coverage, so there’s all kinds of weird stuff about our policy.

        I’ll be 100% honest, I was soo tempted to give up on the $600 error, and just pay the bill. Had it not been for my blog, I probably would have. But I didn’t want to have to admit to others that I was too lazy to keep making phone calls for $600. Damn accountability!

  9. MomofTwoPreciousGirls

    The worst I experienced was my daughter was having her 2yo checkup, during which the DOCTOR brought up that her skin was dry. It was kind of a “duh” moment. But I’ve suffered from dry skin and really it’s not life or death, so I wasn’t concerned. But he decided to write a script for something I used once bc it was like coating her in bacon grease. Next thing I know I get an explanation of benefits and I was not happy. He billed the insurance company for the well exam and then billed as if she had a whole second visit. So if his office charges $125 for each visit he charged $250 total. An extra $125 for a moment of talking and writing. I think things like that are a big part of the reason healthcare is so expensive. I would have been fine to tack on $25 for the “diagnosis” but that was outrageous. They refused to change it.

    • That does seem kind of sketchy. In all honesty, the doctor probably was being thorough and there was a disconnect between coding, billing, and what the visit was actually about. You can use a modifier and add an extra treatment onto a regular office visit in some circumstances, but that doesn’t seem right in this circumstance. I do think this will get worse as private practice becomes a thing of the past and all doctors will be in more clinic type settings.

  10. I don’t see how it would come back to haunt you? It can’t be factored into any pricing anymore by insurance companies. There are really only a few things that can be factored in, and even those have a limit as far as how high of a multiple to the lowest premium it can be. Anyway, I wouldn’t worry about having things in your medical record.

    Even though you only talked about it for 5 minutes I think the coding was correct, unfortunately. If you talk about something that typically doesn’t fall under a routine physical, there are additional codes. Your doctor – or paperwork provided – should warn people that there may be other bills. Like you suggested, I would just ask next time to make sure.

  11. And sometimes they like to bill for services not provided. I had to dispute a cortisone shot they said they gave, but did not. I mentioned that my deductible was already paid, so it would n’t cost anything if I did get the shot, but decided against it.

    Low and behold, the shot was on my bill. As it turned out, they were not in the network, and I was billed.

    • I’m sure that happens more than you would think either intentionally or by accident. That one should be removed from the bill without question!

  12. Annual physicals at no cost to the patient remind me of cheap oil change offers. Once your car is in the shop, the technician invariably finds other things that need maintenance. The same holds true for our bodies – something else always needs some attention.

    My guess is that you are not alone in combining a physical with a few “oh by the way” conditions. This could become very common.

    • I guess it’s becoming a big problem either by people who know they need more than a physical but try to get everything lumped in and by people who just don’t know and then get billed for something they had no idea about. I really think it’s up to the provider to explain and if a cost isn’t brought up, it shouldn’t be billed. It can make for some uncomfortable conversation, but I like the patient to know what to expect.

  13. I literally JUST had to do this (and am actually writing a post on it as well….thanks a lot for beating me to it. LOL). We had done our homework ahead of time and knew that an office visit should have been free of charge, but they charged us coinsurance….when I called and challenged them, the person on the phone agreed with me and sent it back in to be reprocessed.

  14. I have had to dispute a medical bill. It was a very unpleasant conversation, and a lot of backtracking and checking accounts. A big headache if you ask me.

  15. Unfortunately, I have a lot of experience in this arena. My father has serious health problems, and cannot manage his insurance issues. I used to work in health care, so I took over managing all of this stuff a few years back. I make several hundred phone calls a year dealing with his medical billing mistakes. I am not kidding, unfortunately. Mistakes are so common that I even sometimes don’t bother fixing some of the small errors, as I know how much time it takes to correct them, and I have finally put a value on my time.

    Last week I received 3 medical bills IN ONE DAY that all had errors. Each had a different type of error. Sometimes it was on the billing/doctor side, sometimes on the insurance processing side, sometimes on the secondary insurance side….. I often figure out what the mistake is before the billing office/insurance, but sometimes they are random and there is nothing you can do but start calling, and usually….. start spending a lot of time on hold.

    What I appreciated the most from this blog post was her advice to BE NICE. It is incredibly difficult at times, but she is so right – it never helps. It is very hard because some of the customer service agents can’t figure out the mistakes, or are not patient themselves, or are condescending, or honestly…. are not that experienced/smart. The worst is when they say they are fixing something, and just don’t. I have learned that if the first person you talk to often cannot figure out the problem, so if they do not seem to be helpful/knowledgeable, then ask for the SUPERVISOR. The supervisor is more experienced and usually can figure it out. And even if the supervisor cannot, you ask for THEIR supervisor.

    I have also learned that the reputation/quality of your health insurance has a dramatic impact on the number of errors and how they are corrected. My father has 77 unprocessed medical claims sitting on a file on his dining room table that I add to/take away from each day, as errors get fixed and payments are finally sent out. It takes me several hours a week to stay on top of them.

    I absolutely hate it.

    But thank goodness I am here to help my father. There is no way he could manage it. And the sad thing, is that many older people cannot manage working through all of these errors, and probably wind up paying for things they should never had paid for.

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