If your insurance company won’t pay
If you have health insurance and believe that all or part of your hospital bill should be paid for by your insurance company, but the insurer won't pay and/or the hospital is billing you, there are steps you can take:
- Call the doctor or hospital and make sure they have billed your insurance company.
- Call your insurance company's Member Services phone number on your insurance card or paperwork, and find out why your insurance company has not paid the bill; try to work it out with them
- If you cannot work it out with your insurance company, file a formal grievance with your insurance company immediately; this will prevent the hospital from suing or reporting you to a credit agency until a final determination is made by your insurance company, and enables state regulatory agencies to take action.
- Look in your insurance documents or health plan booklet (called Evidence of Coverage or Summary of Benefits), or call your plan's Member Services, for instructions on how to file a grievance.
- If your problem is urgent, meaning there is a serious threat to your health, your health plan must give you a decision within 3 days. If your problem is not urgent, your health plan must give you a decision within 30 days.
- After you file a grievance with your plan, you should also ask for help from the state agency that regulates your health insurance product:
- If you have an HMO, or a PPO from either Blue Cross or Blue Shield, contact the California Department of Managed Care Help Line at 888-466-2219.
- If you have fee-for-service insurance or a PPO through an insurance company other than Blue Cross or Blue Shield, contact the California Department of Insurance or call them at 1-800-927-4357 to file a complaint or ask for an Independent Medical Review.
- If you have Medi-Cal or Healthy Families, see the Health Consumer Alliance Medical Debt Fact Sheets #1 and #2 for how to file an appeal.
- Write down the name and telephone number of anyone you talk to about your bill, and the date of the conversation. Keep copies of any letters and other documents you send so you have proof that you sent them. Fax letters and documents and keep the fax delivery confirmation as proof that the provider got your fax. If you don't have access to a fax machine, you can send your letter certified mail and ask for a return receipt. The return receipt is your proof that the provider got your letter.
- If your insurance policy excludes coverage for some of the care you received, or limits coverage to an arbitrary number of days or dollars below what was medically necessary, the hospital may try to bill you the inflated Chargemaster rate for the services not covered by your insurance. While this is technically legal, you can ask the hospital to treat you as though you are uninsured for those services or days, and ask them not to bill you more for those services than your insurer would pay if they were covered. Ask the hospital to show you that their charges for the uncovered serves are based on a discounted rate (e.g., another insurance company, Medicare or Medicaid) and not on their Chargemaster rate.
Balance Billing: Some consumers protected, some not
If a doctor or hospital is billing you because your insurer didn't pay as much as the doctor or hospital wants, you are being "balance billed," an increasingly common (and sometimes illegal) practice that unfairly puts the consumer in the middle of a billing dispute between the health insurer and the doctor or hospital.
In October 2008, California's Department of Managed Health Care (DMHC) set rules to restrict balance billing for emergency services, but only for the products they regulate (e.g., HMOs, Blue Cross PPOs and Blue Shield PPOs). Consumers with health coverage regulated by the California Department of Insurance (CDI) (e.g., PPOs sold by companies other than Blue Cross and Blue Shield, and other kinds of plans) are NOT protected by the DMHC rules.
If you are not sure which agency regulates your health insurance product, call the DMHC Help Center at 888-466-2219 to ask.
If your insurance policy excludes coverage for medically necessary care, or pays only a tiny part of the bill, you may have junk insurance. The Affordable Care Act of 2010 will outlaw junk insurance beginning in 2014, by setting new minimum standards for health insurance. Until then, visit our Public Policy page to learn how to protect yourself from junk insurance.