Tips for Decoding Your Medical Bills

A billing error can be expensive and may even cause your insurance provider to deny a claim it might otherwise pay. Decoding your own medical bills, however, is not an adventure for the faint of heart. Medical bills are a tangled web of confusing codes, disjointed notes, and potentially unfamiliar language. Still, understanding your medical bill can help you fight insurance denials and avoid paying for care you didn’t receive. Here’s how to interpret the apparent hieroglyphics of medical billing.

1. Request an Itemized Medical Bill

Before you begin your investigation, make sure the document you’re looking at is the correct bill. After a hospital stay, most patients receive several reports that list charges, services, and billing codes. An insurer’s explanation of benefits may look a lot like a bill. Check to ensure the bill came from the doctor or hospital before doing anything else.

Next, ask for an itemized bill. Most medical bills just list the date of service and the price, without detailing the reasons for the charges. You have a right to an itemized bill, though, so request one in writing, through a letter or an email to the billing department at the medical facility that sent the invoice. You may also be able to request an itemized bill through your provider’s online portal. You should receive the new bill within one to two weeks.

2. Get Your Medical Records

To know whether your medical bill is accurate, you must first know which services you received. If you only had a check-up or a simple lab test, it is easy enough to determine what should be on your bill. If it’s for an emergency room visit; childbirth; or any other procedure that involves multiple providers, several medications, or an extended hospital stay; you might not remember every detail. So decoding your medical bills is really about comparing them to your medical records.

Contact your doctor or hospital in writing to request your records. They can charge you a fee for copying the records, but can’t withhold them for other reasons, such as an inability to pay your medical bill. It can take several weeks to get your medical records, so consider ordering them immediately following a hospital stay or medical procedure, even before you receive the bill.

Note that understanding your medical records can be an undertaking unto itself. Some medical records contain lists of standing orders, which are standard procedures for various situations, not necessarily details about what you received. For instance, a hospital might have a standing order for inducing labor that includes Pitocin and intravenous fluids. If you see something that looks unfamiliar, check the notes to assess whether it’s something you received. You can also call your provider if something seems amiss.

3. Understand Billing Codes

Understanding your medical bill is really about understanding billing codes. Your itemized bill should contain a list of procedures, each with a brief description and several numbers listed alongside it. The description can illuminate the purpose of the procedure, but it’s the billing code that matters for insurance coverage. This five-digit code is standardized across hospitals and providers.

Unfortunately, the procedures to which codes refer can be challenging to access. It is sometimes proprietary, and behind a paywall, so you may have to search several different sources. The Centers for Medicare and Medicaid Services has a code searching tool. Ignore pricing information, since that applies only to Medicaid and Medicare providers.

4. Decode Diagnostic Numbers

The next number to look for is the diagnostic code attached to each item on the bill. This three-digit number is standardized across facilities. Like the billing code, however, it can be difficult to find what it means. Try checking the ICD-10 search database to understand the diagnostic code. If the results of that search are unhelpful, contact your provider.

The goal of searching diagnostic codes is to ensure the right diagnosis is attached to the procedure. Insurers sometimes will decline to cover a procedure if the diagnostic code is incorrect. And sometimes, an incorrect diagnostic code indicates a procedure that you didn’t have — or that you shouldn’t have had.

5. Check for Double Billing

One of the most common billing errors is double billing. So scour your bill for this common practice. Some examples of double billing include:

  • Billing multiple times for a procedure that you had only once.
  • Billing for the component parts of a procedure — for instance, some vaccination injections contain multiple vaccines. It’s generally impermissible to bill for each individual vaccine rather than the combined immunization. The same is true of laboratory blood tests.
  • Two providers billing for the same procedure.
  • Billing multiple insurers for a procedure — you’ll typically only notice this occurrence of double billing if an insurer declines to cover a procedure and you have to fight the denial.

6. Identify Other Common Billing Issues

Some other issues to check your bill for include:

  • Theater time. When you have a medical procedure, you’ll be charged for the operating or other room, usually referred to as an operating theater. Make sure the time listed matches the amount of time you spent in the room.
  • Math errors. The individual charges listed on the bill should add up to the bill total.
  • Medication issues. You should only be billed for medications you used. Sometimes doctors prescribe medications and then change their minds. In other cases, a doctor might order over-the-counter drugs that never made their way to your room.
  • Unreasonable supply charges. Were you charged $100 for a maxi pad? $20 for a single ibuprofen tablet? This cost inflation is very common. Contact the provider to let them know you dispute the amount. In many cases, they’ll automatically adjust the charges if you offer resistance.

7. Deal With Insurance Issues

If your insurer refuses to cover all or a portion of your care, erroneous billing practice might be the culprit. So decoding your medical bill often requires comparing the bill to your insurance statement. This statement, called an explanation of benefits, should contain a list of each procedure for which the insurer was billed.

The billing code for each procedure should match the code on the itemized bill from the provider. Next to each code, the insurer should note whether the procedure was covered and, if coverage was denied, the reason for the denial. Once you know the reason for the denial, you may be able to appeal the denial of coverage based on your insurer’s policies. In other cases — such as denial because of double billing — you should directly dispute the bill, in writing, by contacting the provider.

If you’re still struggling, you may be able to get help. A medical billing advocate is a trained reviewer who can comb through your bill, search for errors, and help you fight unfair charges. Many companies provide this service. If your bill is sufficiently high, a lawyer might even be interested in taking on the cause. Contact your local Bar Association for assistance locating a lawyer who specializes in health care billing disputes. Before doing anything else, however, notify the provider in writing that you dispute the bill. Doing so can slow the collections process and give you time to decide what to do next.