Fix a medical bill

---
name: medical-bill-review
description: Review a US medical, hospital, dental, lab, or ambulance bill for errors and overcharges, and help the person lower it, appeal it, or get financial assistance. Use this whenever someone shares or describes a medical bill, an Explanation of Benefits (EOB), a surprise out-of-network bill, a bill that seems too high, an insurance denial, a medical collections notice, or asks how to negotiate or get help paying a healthcare bill.
---

# Medical Bill Review

Last verified: September 2026. US-focused. Coverage rules and state protections vary, so verify anything that decides whether a bill is owed.

## Why this skill exists

Medical bills are frequently wrong, and even correct bills are often negotiable. Most people pay the first number they see because the codes are unreadable and the process is intimidating. A careful, line-by-line review plus the right request to the right office regularly saves hundreds or thousands of dollars.

## Privacy first

Medical bills contain sensitive information. Ask the person to redact things you don't need: Social Security number, member ID, full date of birth, and account numbers. You need codes, descriptions, dates, quantities, and amounts. Don't repeat diagnoses back unnecessarily.

## Step 1: Get the right documents

A summary bill ("amount due: $4,812") isn't reviewable. Ask for:

1. **Itemized bill** from the provider or hospital, with CPT/HCPCS codes, revenue codes, dates, quantities, and charges per line. Patients are entitled to request one; tell the person to call billing and ask specifically for "an itemized statement with billing codes."
2. **Explanation of Benefits (EOB)** from the insurer for the same dates of service, if insured.
3. **Good Faith Estimate**, if they were uninsured or self-paying and received one.
4. Any **notice and consent form** they signed agreeing to out-of-network care.

## Step 2: Reconcile the bill against the EOB

The EOB is the insurer's version of what happened and what the patient owes. Check:
- Does the "patient responsibility" on the EOB match the bill? If the bill asks for more, the provider may be billing above the in-network allowed amount, which is usually not allowed for in-network providers.
- Was the claim processed at all? Many bills arrive before insurance has paid.
- Was anything denied? Note the denial reason codes.

## Step 3: Line-by-line error scan

Flag each line that fits one of these patterns. Treat these as questions to ask, not accusations:

- **Duplicates**: same code, same date, billed twice
- **Services not received**: medications, supplies, or procedures the patient doesn't recall
- **Quantity errors**: e.g., 10 units of something that was given once
- **Date errors**: charges for days after discharge, or a full day charged for the discharge day
- **Upcoding**: e.g., the highest-level ER visit code for a minor issue; ask the provider to justify the level
- **Unbundling**: components billed separately that are normally included in one procedure code
- **Canceled services still billed**: tests ordered then canceled
- **Room and board**: private room charges when a semi-private room was provided
- **Facility fees**: unexpected fees at hospital-owned clinics; ask whether they were disclosed

Look up unfamiliar codes. Use Medicare's physician fee schedule or the hospital's own price transparency file as rough reference points for what the service commonly costs. Hospitals are required to publish standard charges, including cash prices.

## Step 4: Check for surprise billing protections

The **No Surprises Act** (in effect since 2022) generally protects patients with private insurance from balance bills for:
- **Emergency care**, including at out-of-network facilities, charged no more than in-network cost sharing
- **Out-of-network providers at in-network facilities** (e.g., anesthesiologists, radiologists, pathologists, assistant surgeons, hospitalists), who generally can't get patients to waive these protections
- **Out-of-network air ambulance** (ground ambulance is not covered federally; some states protect it)

For non-emergency care, a provider may get the patient to waive protections through a proper written notice and consent in advance, with exceptions for the ancillary providers above.

**Uninsured or self-pay patients** are entitled to a Good Faith Estimate. If the final bill is at least $400 more than the estimate, they can start the patient-provider dispute resolution process, generally within 120 days of the bill.

If a bill appears to violate these protections, the person can dispute it with the provider and insurer and complain through the federal No Surprises help line and CMS. Many states have their own additional protections.

## Step 5: Insurance appeals (if something was denied)

- Internal appeal to the insurer, usually within 180 days of the denial for most plans
- Ask the provider for a letter of medical necessity and the relevant records
- If the internal appeal fails, request an **external review** by an independent reviewer
- Check whether it was a coding problem the provider can fix by resubmitting; that's often faster than an appeal

## Step 6: Lower what's actually owed

Even with no errors:
- **Financial assistance / charity care**: nonprofit hospitals must have a financial assistance policy and must accept applications for a period after the first bill (at least 240 days). Eligibility often reaches well into middle incomes. Always ask, even if the person doesn't think they qualify. Many states require discounts too.
- **Prompt-pay or cash discount**: ask what discount is available for paying in full.
- **Negotiate to a benchmark**: offer a specific amount based on typical cost or Medicare rates.
- **Interest-free payment plan**: hospitals commonly offer these. Suggest this over putting the bill on a credit card or a medical credit card, which may charge deferred interest.
- Ask the provider to **pause collections** while a review, appeal, or assistance application is pending.

## Step 7: Collections and credit reports

- Don't pay a collector before validating the debt. Under the Fair Debt Collection Practices Act, send a validation request in writing, ideally within 30 days of first contact.
- A debt stemming from a bill that violates the No Surprises Act may not be legitimately collectible.
- The three major credit bureaus don't report paid medical collections, collections under $500, or medical collections less than a year old.
- The federal rule that would have removed all medical debt from credit reports was **vacated in July 2025** and is not in effect. Some states have their own restrictions; check the person's state.

## Output format

1. **Summary**: total billed, what the EOB says is owed, estimated amount in question
2. **Flag table**: line, code, description, charge, issue, question to ask
3. **Protections check**: No Surprises Act / GFE dispute / appeal eligibility, with deadlines
4. **Action plan**, in order
5. **Scripts and letters**: call script for billing, itemized bill request, dispute letter, financial assistance request, or validation letter, whichever apply

## Don't

- Don't tell someone to ignore a bill. Unpaid bills can go to collections even when they're wrong. Recommend disputing in writing and asking for a collections hold.
- Don't state that a charge is fraudulent. Frame findings as errors to verify.
- Don't give medical advice about the underlying care.
- You're not a lawyer. For large bills or lawsuits, suggest a patient advocate, legal aid, or an attorney.