Negotiate a medical bill, one letter at a time

Which letter to send first

1. The itemized bill. The first bill is usually a summary: a few lines like "pharmacy" and "room and board" with a total. You can't question a charge you can't see, so ask for every line with its date, billing code and price.
2. Dispute what's wrong. Look for the same thing billed twice, a test or medicine that was never given, and days you weren't there. Compare each line with the insurer's explanation of benefits for the same dates, and send one letter listing every charge you're disputing.
3. Ask for financial assistance. Nonprofit hospitals must have a program that lowers or forgives bills for people who qualify. If yours isn't a nonprofit, ask anyway. The letter gets you the policy and the application form, and the form is what counts, so fill it in and send it back as soon as you have it.
4. Then talk about money. Once the bill is correct and any assistance is applied, offer what you can pay at once, or ask for a monthly plan. Get any agreement in writing before you pay.

Send each letter by mail with tracking or through the hospital's patient portal, and keep a copy. When you call, write down the date, who you spoke to and what they said. A letter puts a date on what you asked for. A phone call doesn't.

What the law gives you

HIPAA covers billing records. The privacy rule gives you a right to a copy of your designated record set, and it defines that set as both the medical records and the billing records a provider keeps about you. So a written request for the itemized bill is a HIPAA access request, and the provider has 30 days to act on it. It's the same right you'd use to get the chart itself, with our medical records request letter.

Nonprofit hospitals have rules of their own. To keep their tax exemption, they must have a written financial assistance policy, and a patient who qualifies can't be charged more than what the IRS calls "amounts generally billed" for emergency or medically necessary care. Under the IRS billing and collection rules, the hospital can't take an extraordinary collection action, such as reporting the debt to a credit bureau, selling it, or suing, until at least 120 days after the first bill sent after the patient leaves. You have at least 240 days from that same bill to apply. Once the hospital has a complete application from you in that window, it has to pause those actions while it decides.

These rules apply to nonprofit hospitals only. A for-profit hospital, or a doctors' group that bills you separately, doesn't have to follow them. Outside that pause, asking a billing office to hold off on collections is a request, not a right.

A worked example: Maria and her father's hospital bill

Maria's father, Luis, spends four days at Riverside General, a nonprofit hospital, in late May. On June 12 a bill for $18,400 arrives: six lines and a total. Maria holds his healthcare power of attorney, so she writes the letters, and a copy of the power of attorney goes in each envelope. A billing office can refuse to discuss an account with a relative. Without that kind of authority, have the patient sign the letter with you.

Her first letter asks for the itemized bill. It comes back with 140 lines, and two of them are the same chest CT on May 30. Her second letter lists that charge and asks for a corrected statement. The same week she sends the financial assistance letter, gets the application form, and returns it with her father's Social Security statement.

She has time. Counting from June 12, the hospital can't report the bill to a credit bureau, sell it or sue before October 10, and Luis has until at least February 7 to apply. If the assistance decision still leaves a balance, Maria's last letter offers a monthly amount, and the plan comes back in writing.