Your rights

Your rights on a medical bill.

Eight rules that protect you, in plain English. Each one shows its deadline, what to do, and the official source. Ahem uses these to check your bill and write your letter.

Ask for the itemized bill

A summary bill hides the mistakes. Ask for the fully itemized bill: every line with a date, a code, units and a charge. Hospitals produce it on request. If you're on Medicare, you have a right to an itemized statement.

Deadline: Ask right away. Don't pay first.
What to do: Itemized bill request
Source: www.cms.gov

Your medical records (HIPAA)

Federal law (45 CFR 164.524) gives you your own records. They must answer within 30 days, with one 30-day extension. The records prove what actually happened, so you can match them to what you were charged.

Deadline: 30 days from your request
What to do: HIPAA records request
Source: www.hhs.gov

No Surprises Act

For emergency care, and for out-of-network doctors working inside an in-network hospital, you generally can't be billed more than your in-network share. If you're uninsured or paying cash, you can dispute a bill that's $400 or more above your Good Faith Estimate.

Deadline: Dispute within 120 days of the bill (uninsured / self-pay)
What to do: No Surprises complaint / dispute
Source: www.cms.gov

Appeal a denial

Insurers deny about 1 in 5 in-network claims on the ACA marketplace, and fewer than 1% of those denials get appealed. You can appeal inside the insurer first, then ask an independent reviewer outside the insurer to decide.

Deadline: Use the deadline on your denial letter (often 180 days)
What to do: Internal appeal + external review
Source: www.kff.org

Charity care (nonprofit hospitals)

Nonprofit hospitals must have a financial assistance policy under IRS rule 501(r). Many families qualify at incomes well above poverty. While you apply, the hospital can't report you to credit bureaus, sue you or sell your debt until it has screened you. If you qualify, they must refund what you overpaid.

Deadline: Apply within 240 days of the first bill after discharge
What to do: Financial assistance application
Source: www.irs.gov

Hospital price transparency

Hospitals must publish their negotiated prices in a public file (45 CFR 180). Ahem compares your line items to the hospital's own numbers.

Deadline: Any time
What to do: Price check
Source: www.cms.gov

Medical debt + credit reports

The three credit bureaus no longer report paid medical collections or medical collections under $500. They also wait a year before reporting new medical debt. If you see one of these on your report, dispute it for free directly with the bureau. Ahem never charges for credit disputes.

Deadline: 1-year grace before reporting
What to do: Free credit check
Source: www.consumerfinance.gov

Collectors must validate

If a debt collector contacts you, you can demand proof of the debt. If you dispute it in writing during the validation period, collection has to pause until they verify.

Deadline: Within the validation period on their first notice
What to do: Debt validation letter
Source: www.consumerfinance.gov

Glossary

Every word on the bill, in one line each.

EOB (Explanation of Benefits): Your insurer's receipt. It's not a bill. It shows what was billed, what the insurer allowed, what it paid, and what YOU owe. That last line is the number to match against the hospital bill.
Patient responsibility: What you actually owe after insurance. If the hospital bills more than this, that's a red flag.
Allowed amount: The price your insurer agreed to. In-network providers can't bill you the difference between their sticker price and this.
Chargemaster: The hospital's sticker-price list. Almost nobody with insurance should pay these prices.
Itemized bill: The line-by-line version of your bill. Always ask for it.
CPT / HCPCS code: 5-character codes for what was done (a scan, a visit, a drug). The wrong code means the wrong price.
Revenue code: 4-digit hospital department code (for example, 020x = ICU room). It helps you check room days and supplies.
ICD-10 code: Diagnosis code. It explains why care was given and drives medical-necessity decisions.
UB-04 / CMS-1500: The claim forms hospitals (UB-04) and doctors (CMS-1500) send your insurer. Ask for a copy.
Deductible: What you pay each year before most insurance kicks in.
Coinsurance / copay: Your share after the deductible: a percent (coinsurance) or a flat fee (copay).
Out-of-pocket max: The most you pay in a plan year for covered in-network care. After that, your plan pays 100%.
In-network / out-of-network: Whether the provider has a contract with your plan. The No Surprises Act protects you in many out-of-network situations.
Balance billing: Billing you for the gap between the sticker price and what insurance paid. Often banned.
Prior authorization: Insurer pre-approval. A missing prior auth is a common reason for denials, and those denials are often fixable.
Medical necessity: Whether care was needed. Denials for this reason are often overturned with a doctor's letter.
Unbundling: Billing separately for parts of a procedure that should be one charge.
Upcoding: Billing a more expensive code than the care given.
NCCI / MUE edits: Medicare's rules for code pairs that shouldn't be billed together and the maximum units per day. Useful red flags, though commercial plans differ.
Observation status: You can be in a hospital bed and still be 'outpatient.' It changes what you owe, especially on Medicare. Ask: was I admitted or under observation?
FAP / charity care: A hospital's Financial Assistance Policy. Required at nonprofit hospitals.
AGB (Amounts Generally Billed): If you qualify for financial assistance, a nonprofit hospital can't charge you more than what insured patients are generally billed.
ECA (Extraordinary Collection Action): Credit reporting, lawsuits, liens, wage garnishment, selling your debt. Restricted while a charity-care application is pending.
GFE (Good Faith Estimate): A written price estimate you're owed if you're uninsured or paying cash for scheduled care.
PPDR: Patient-Provider Dispute Resolution. Lets uninsured or cash-pay patients dispute a bill that's $400+ over the GFE.
External review: An independent reviewer, outside the insurer, who can overturn a denial. Only about 40% of people know it exists.

Want this as a printable kit with the phone scripts and letters? See the Giant Slayer Toolkit.

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