How do I tell if a medical bill is inflated?

Short answer: You can identify a potentially inflated medical bill by comparing the charges to your Explanation of Benefits (EOB), researching typical costs for similar services in your area, and scrutinizing itemized bills for errors, duplicate charges, or unbundling.

Identifying an inflated medical bill requires careful review and comparison. Many factors can contribute to medical bill discrepancies, ranging from honest coding errors to more problematic practices.

Review Your Explanation of Benefits (EOB)

Your insurance company sends an Explanation of Benefits (EOB) form after you receive medical care [S1]. The EOB is not a bill but a summary of what services were covered, what the insurer paid, and what you might owe. Compare your medical bill directly with the EOB. Look for discrepancies between the services listed, the dates of service, and the amounts billed versus the amounts approved or denied by your insurer [S1]. Ensure all services listed on the bill were actually received.

Scrutinize the Itemized Bill

Always request an itemized bill, not just a summary. An itemized bill breaks down every service, medication, and supply with specific codes and costs. Look for:

Duplicate charges: The same service or item billed multiple times [S2].
Upcoding: Billing for a more expensive service than the one actually provided [S2].
Unbundling: Billing separately for services that are normally included in a single procedure code [S2]. For example, charging for bandages and sterile gloves individually when they should be part of a surgical procedure charge.
Services not rendered: Charges for tests, procedures, or items you did not receive [S2].
Incorrect patient information: While not directly inflating the cost, errors in your name, policy number, or date of birth can lead to billing issues and denied claims [S3].

Research Fair Market Prices

Numerous online tools and resources allow you to search for the typical cost of medical procedures and services in your geographic area. Websites like Healthcare Bluebook, FAIR Health Consumer, and the Medicare Procedure Price Lookup provide estimated costs which can help you gauge if your bill is significantly higher than average [S4, S5]. Keep in mind that prices can vary widely based on facility type (e.g., hospital vs. outpatient clinic) and location [S4].

Check for Balance Billing (If Applicable)

Balance billing occurs when a healthcare provider bills you for the difference between what they charged and what your insurance plan paid, often because the provider is out-of-network [S6]. The No Surprises Act, effective January 1, 2022, protects consumers from surprise medical bills for certain emergency services and non-emergency services provided by out-of-network providers at in-network facilities [S6]. If you receive a bill that seems to be balance billing for services covered by this act, it may be inflated or illegal.

What to do:

Request an itemized bill and your Explanation of Benefits (EOB).
Compare your itemized bill line-by-line with your EOB.
Research fair market prices for the services received in your area.
Contact the provider's billing department to dispute suspicious charges.

Sources

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