Medical Bills After an ER Visit: What to Do When They Arrive
Recently, someone in my family had an unexpected trip to the emergency room.
There is a strange moment after something like that. You are finally home. The person you love is slowly recovering. You start returning to normal routines.
And then the medical bills start arriving.
Even with health insurance, the amount a family may owe can be significant. Deductibles, coinsurance, copays, out-of-network charges, ambulance services, and separate bills from physicians or other providers can turn one emergency visit into several financial decisions.
This is something I think families should prepare for before the envelope arrives.
And if you open that envelope and the number is sky high, my first suggestion is simple:
Do not assume the first number you see is necessarily the final amount you owe.
There is some homework to do first.
Before an Emergency, Know Your Health Insurance Numbers
Most of us know our monthly health insurance premium.
Fewer of us know the numbers that may matter considerably more during an emergency.
Log into your health insurance account and find your:
Deductible: What you generally pay for covered services before your plan begins paying according to its terms.
Coinsurance: The percentage of certain covered costs you may be responsible for.
Copay: A fixed amount you may pay for certain services.
Out of pocket maximum: The most you generally pay for covered, in network services during a plan year before the plan pays 100 percent of covered benefits, subject to the plan's terms.
That last number is important.
Ask yourself:
If our family reached our out of pocket maximum this year, where would that money come from?
Emergency savings?
An HSA?
An FSA?
Cash flow?
If the answer is, I am not sure, that gives you something useful to discuss with your financial advisor.
You do not need to predict a medical emergency. You can prepare for the financial possibility of one.
When the Bills Arrive, Create One File
A hospital visit rarely creates one neat bill.
You may receive separate statements from the hospital, emergency physician, radiologist, laboratory, ambulance provider, specialist, or other providers.
Keep everything.
Create one physical folder or digital file for:
Medical bills
Insurance Explanation of Benefits statements
Receipts
Claim numbers
Letters
Notes from phone calls
Names of people you spoke with
Dates and reference numbers
It takes some time, but it's incredibly useful.
Start With the EOB, Not the Bill
(Explanation of Benefits Explained)
Before paying a medical bill, find the corresponding Explanation of Benefits, commonly called an EOB.
The EOB comes from your insurance company. It shows what the provider billed, what the insurer allowed, what insurance paid, and what the insurer believes may be your responsibility.
An EOB is not a bill.
Compare it with the bill from the provider.
Look at the patient name, date of service, provider, services, amount billed, insurance adjustment, insurance payment, and patient responsibility.
If the numbers do not match, stop there and ask questions.
Call the Insurance Company
If something looks wrong, I would start with the insurer.
Have your insurance card, EOB, provider bill, and claim number in front of you.
Ask these questions:
Why is this amount my responsibility?
Was the claim processed as in-network or out-of-network?
Was anything denied?
If so, what was the specific reason?
Was information or documentation missing?
Does the provider need to resubmit or correct the claim?
Does this amount count toward my deductible or out-of-pocket maximum?
Is there an appeal process?
Write down the representative's name and the reference number for the conversation.
If you do not understand the answer, ask them to explain it again.
Medical billing is complicated. You can ask questions until you understand what happened.
Then Call the Provider's Billing Department
Sometimes the problem is surprisingly ordinary.
The wrong insurance information was submitted.
A billing code needs to be corrected.
The insurer needs additional documentation.
The provider was missing information.
A claim needs to be resubmitted.
Ask the provider's billing department whether the claim was submitted correctly and whether they received the insurer's explanation for any denial or reduced payment.
If the bill itself is unclear, ask for an itemized bill.
And if the provider is working on correcting or resubmitting the claim, ask whether the account can be placed on hold while that happens.
The goal is to get the insurance and provider sides talking about the same claim before you decide what you actually owe.
How to Appeal a Denied Health Insurance Claim
The word denied feels final.
It may not be.
The Centers for Medicare & Medicaid Services, or CMS, says consumers generally have the right to appeal when their health insurance company refuses to pay a covered medical bill. An internal appeal asks the insurer to reconsider its decision. Depending on the plan and type of denial, an external review by an independent third party may also be available. (CMS)
Read the denial notice carefully. It should explain why the claim was denied and how to appeal.
Then build your case around the reason for the denial.
If the insurer says a treatment was not medically necessary, for example, ask the treating physician whether additional medical records or a letter explaining the medical necessity may help.
If prior authorization is the issue, ask the provider what records exist.
If the insurer says the provider was out of network, ask how emergency care is treated under your plan and whether federal or state surprise billing protections may apply.
Keep copies of everything you submit.
Know About the No Surprises Act
This is especially relevant after emergency care.
The federal No Surprises Act protects many insured consumers from certain unexpected out-of-network bills, including covered emergency room services, certain nonemergency services received at an in-network facility, and air ambulance services. The protections do not apply to every medical expense or situation. (CMS)
If you receive a large out-of-network bill after an emergency room visit, do not automatically assume the entire balance is correct.
Ask your insurer and provider whether the No Surprises Act applies.
If the Bill Is Correct but You Cannot Afford It, Ask for Help
Sometimes you do all the checking, and the bill really is yours.
That does not necessarily mean your only option is putting the entire amount on a credit card.
Ask the hospital about its financial assistance policy.
Federal tax rules require tax-exempt hospitals to maintain written financial assistance policies explaining eligibility, available assistance, and how patients can apply. (IRS)
Do not assume you earn too much to qualify. Ask.
Also ask the billing department whether there is a payment plan or other payment option available.
The Consumer Financial Protection Bureau suggests asking whether a provider will negotiate a bill or offer an interest-free repayment plan. It also cautions consumers to think carefully before moving medical debt onto a credit card or medical credit card because interest costs may be high and doing so could affect your ability to negotiate the original bill. (Consumer Financial Protection Bureau)
That is an important distinction.
Before turning a medical bill into credit card debt, understand the alternatives.
Give Someone Else Permission to Help
When you're recovering from a medical emergency, the last thing you may want to do is spend an hour on the phone discussing billing codes.
This is where family can help.
CMS specifically notes that friends, family members, Consumer Assistance Programs, and patient advocates may be resources when someone is sick or overwhelmed by a billing issue. (CMS)
Ask the insurer or provider what authorization is required for a spouse, adult child, or other trusted person to discuss the account on your behalf.
Sometimes the most useful financial help is simply having someone else make the calls.
Plan for the Medical Bill Before There Is One
This recent experience with my family reminded me of something I tell clients often.
An emergency fund is not only for a broken water heater or unexpected car repair.
Healthcare belongs in that conversation, too.
Consider looking at your health plan's out of pocket maximum and asking:
Could we reasonably absorb this amount in one year?
If not, perhaps that becomes part of your savings plan.
If you have access to an HSA or FSA, understand how it works and what qualified expenses it may cover.
Know where your insurance information is.
Make sure your spouse or another trusted person knows where it is, too.
My Medical Bill Checklist
When a large bill arrives, I would work through it in this order:
Do not panic and immediately pay it.
Find the matching EOB.
Check the bill for errors and request an itemized statement if needed.
Call the insurer and understand exactly how the claim was processed.
Call the provider if something needs to be corrected or resubmitted.
Appeal a denial when appropriate and pay close attention to deadlines.
Check whether No Surprises Act protections may apply.
Ask about hospital financial assistance.
Ask about payment arrangements before automatically using a credit card.
Document every conversation.
Then, when you understand what you actually owe, you can make a more informed decision about how to pay it.
The person in my family is home now.
Slowly getting better.
The bills are still arriving.
And in a strange way, that feels like its own stage of recovery.
Medical emergencies remind us how quickly life can change. We cannot plan for every diagnosis, every emergency room visit, or every bill.
But we can know our insurance.
We can keep some money available for the unexpected.
We can ask questions.
We can appeal when something appears to have been processed incorrectly.
And we can resist the instinct to assume that a frightening number printed on a medical bill is automatically the final answer.
Sometimes the first step is simply picking up the phone and asking:
“Can you walk me through exactly why I owe this?”
That is a very good place to begin.
Frequently Asked Questions:
What's the difference between an EOB and a medical bill?
An EOB, or Explanation of Benefits, comes from your insurance company and shows what the provider billed, what the insurer allowed, what the insurer paid, and what it believes you owe. It's meant to be compared against the actual bill from the provider to make sure the numbers match before you pay anything.
What should I do first when a medical bill arrives?
Don't pay it right away. Find the corresponding EOB first and compare it to the bill — checking the patient name, date of service, provider, services, amount billed, insurance adjustment, and patient responsibility. If the numbers don't line up, that's the point to stop and start asking questions.
Can I appeal a denied insurance claim?
Often, yes. According to CMS, consumers generally have the right to appeal when an insurer refuses to pay a covered medical bill, starting with an internal appeal asking the insurer to reconsider, and in some cases followed by an external review from an independent third party, depending on the plan and type of denial.
What is the No Surprises Act, and does it apply to ER visits?
The federal No Surprises Act protects many insured consumers from certain unexpected out-of-network bills, including covered emergency room services, some nonemergency services at in-network facilities, and air ambulance services. It's worth asking your insurer and provider directly whether it applies to your specific bill, since the protections don't cover every situation.
What if I can't afford a medical bill, even after confirming it's correct?
Ask the hospital about its financial assistance policy; tax-exempt hospitals are required to have a written policy explaining eligibility and how to apply, so it's worth asking even if you're not sure you'd qualify. You can also ask the billing department about payment plans, and consider talking to the provider about negotiating the bill before putting it on a credit card, since interest costs can be high and it may limit your ability to negotiate later.
Can someone else help me handle medical billing calls?
Yes. CMS notes that friends, family members, Consumer Assistance Programs, and patient advocates can be a resource when someone is sick or overwhelmed by a billing issue. It's worth asking your insurer or provider what authorization is needed for a spouse, adult child, or other trusted person to discuss the account on your behalf.
This material is for general educational purposes only and is not individualized financial, insurance, tax, legal, or medical advice. Health insurance coverage, appeals rights, billing protections, financial assistance, and payment options vary by plan, provider, state, and individual circumstances. Review your plan documents and consider consulting the appropriate insurance, healthcare, legal, tax, or financial professionals regarding your circumstances.
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