Did your patient dispute a surprise medical bill? Here’s what to do next.
Forty-five percent of insured, working age adults say they received an unexpected medical bill in the last year, according to the 2023 Commonwealth Fund Health Care Affordability Survey. And while fewer than half of these respondents disputed those bills, there’s a growing awareness of when and how to do it. That’s all thanks to the No Surprises Act, the federal law that mandates transparency regarding healthcare costs and provides certain protections for patients. What does this mean for medical practices? It’s time to ‘study up’ on the patient provider dispute resolution process.
Surprise medical bills: Understand the patient provider dispute resolution
As the awareness of surprise medical bills grows among healthcare consumers, you’ll need to know what to expect if a patient starts the payment dispute resolution process. Follow these five steps to resolve the medical bill dispute:
1. Don’t panic. Just because a patient disputes an unexpected medical bill doesn’t necessarily mean the medical practice made a mistake. Medical bills are confusing, and a simple conversation between the physician and patient could be all that’s necessary to resolve things. A well-informed revenue cycle management team empowered by the right billing technology can also be particularly helpful in helping patients understand why there was a difference between the good faith estimate and surprise medical bill.
2. Be on the lookout for an email link to the federal dispute resolution portal. Once you receive the link, click on it and head to the portal. Here you’ll need to upload the good faith estimate you provided to the patient, the bill you sent to the patient, and any supporting documents that help explain why your bill is higher than the estimate. For example, perhaps the difference was based on a medically necessary item or service that you could not have reasonably anticipated when you provided the good faith estimate. You’ll need to provide all of this information within 10 business days of the patient initiating the patient provider dispute resolution process. Note: Patients can only dispute surprise medical bills that are at least $400 more than the expected charges on the good faith estimate.
3. Respond to the dispute resolution entity. This independent third party assigned to your case may request additional information to resolve the medical bill dispute beyond what you’ve already uploaded into the portal. If it does, respond quickly to keep the patient provider dispute resolution process moving along.
4. Watch for a final decision. Once the dispute resolution entity decides whether and how much the patient owes, it will notify everyone. Note that while you’re waiting for a decision, you could try these approaches to resolve the medical bill dispute:
Invite the patient to speak with a patient financial counselor, medical biller, or medical coder to clear up the confusion regarding the unexpected medical bill.
Provide the patient with a detailed written explanation regarding why the good faith estimate was higher than the surprise medical bill.
Send general educational resources to the patient about the No Surprises Act and specific steps your medical practice takes to comply.
Note that if you’ve already sent the bill to a collection agency, remove it from collections. If you and the patient agree on a payment amount before the dispute resolution entity makes a determination, you’ll need to notify the dispute resolution entity as soon as possible and no more than three days after a settlement is made. Be sure to complete this notice of payment settlement (PDF) (en Español) (PDF), and send it and any supporting documents by encrypted email to FederalPPDRQuestions@cms.hhs.gov.
5. Close the loop. Regardless of whether you reached a settlement together or with the help of the dispute resolution entity—and regardless of whether the settlement was favorable to you or not—you’ll want to acknowledge the patient’s diligence in reviewing their medical bill, apologize for the confusion, and thank them for being a loyal member of your medical practice. You could also encourage them to reach out with any additional questions now or in the future. Convey your willingness to collaborate with the patient and learn from each opportunity.
Looking ahead
As you strive to attract and retain patients, inviting feedback and opening the lines of communication are critical. This pertains to the clinical and administrative sides of your medical practice. The No Surprises Act presents an opportunity for patient engagement and leveraging technology to improve the patient financial experience. Learn how edgeMED can help.
