When we left off last time, Steve and I had completed the financial assistance process. A completely different track was running in parallel.
While exhausting the financial aid process was mandatory to demonstrate full engagement with their internal procedures from start to finish, the “request for information” track was essential for building a parallel administrative record in earnest.
First, it’s important to understand the general methodology for addressing billing concerns with healthcare providers. Issues can fall into many categories, most of which require legal assistance to pursue formally.
As someone not qualified to provide legal advice, the only angle I can handle is through the lens of a billing concern. These are not yet disputes; that requires a separate, distinct classification I’ll address in a later part.
First, we had to identify if there was a verifiable issue. For me to take on a case, there must be an obvious controversy beyond subjective claims like “I was charged too much” or “I wasn’t satisfied with the services.” Those arguments are non-staters.
During intake, Steve provided all relevant documents: itemized billing statements, explanations of benefits, and more. After a thorough review, we identified several items that appeared to require further explanation or supporting documentation. Mind you, this was not a smoking gun, definitive errors, evidence of wrongdoing of any sort. These are quite rare in the initial phases of a healthcare billing concern. These items could easily be explained given the complexities of medical billing structures.
This first letter, a “request for information” (or RFI), is the beginning of a fact-finding mission. Providers maintain their own administrative records to confirm services, accounts, and charges. To proceed fairly, we must build our own parallel record to demonstrate where charges can be independently verified.
If the two records align fully, there is no controversy; I would have to advise Steve that nothing further could be done. On the other hand, we give the provider ample time and opportunity to provide independently verifiable data that bridges any gap, or at least a reasonable explanation for why a gap exists.
One thing I am very clear about is that we were not making accusations. This isn’t a lawsuit motion, but a request for facts. What I had presented was a set of irregularities, not anything that could be considered evidence of wrongdoing.
These letters are fairly long and packed with technical (and frankly, boring) detail. I talk about how these are written here.
However, we intentionally mixed in some straightforward questions with simple, explainable circumstances. For example:
Concern: Two separate charges for [Redacted] at $50.00 each were noted.
Request: Please confirm if these reflect two separate administrations or a duplicate entry.
This is a single-source question—they could check the drug administration record, confirm two doses, and respond accordingly. We knew this from discharge paperwork, so we were essentially asking “what is 2+2,” reasonably expecting “it’s 4”. The strategy here is to gauge how they respond to reasonable, simple requests. This tests consistency, thoroughness, and tone for insights into their overall approach.
So here are the answers they provided:
To start with our single-source question: “Per medication administration record the patient was given 2 administrations of [redacted].”
We promptly responded “no further concerns” on this specific item in later correspondence, and it confirmed they are capable of providing independently verifiable information when there is no controversy involved.
As for the other responses, I’ll let readers judge for themselves:
“[Price or Rate] is correct per our organization’s Revenue Integrity Director.
“[Redacted] billed at $450 x 2 is for professional anesthesia charges. They are coded correctly as one charge is for [Redacted] and the other is for [Redacted].
“Per TB modifier – drug are priced by 340b drug pricing discount program. Medications follow a price table of cost x markup.”
“There are 2 charges because there are 2 separate bills for each service. One is for the facility charge and one is for the professional charge. Dr. [Redacted] is listed as the attending provider on the facility claim for hospital services. Dr. [Redacted] is the performing surgeon, and those charges are for his professional services.”
These are all well-meaning explanations, but they largely consist of assertions rather than the independently verifiable data or documentation we requested (e.g., formulas, breakdowns, or supporting records that could be cross-checked externally). Many rely on internal confirmation, such as “correct per our organization’s Revenue Integrity Director,” which functions as an appeal to internal authority.
To be fair, hospitals must protect proprietary and competitive information—pricing methodologies, markups, and internal formulas are sensitive in a market with nearby competitors. Full disclosure could impact their position, so limited responses are understandable and common.
Still, these replies provided useful insights for our next steps. For instance, the repeated reliance on the Revenue Integrity Director signaled strong internal confidence in the pricing data. This indicated that pressing further on pure pricing matters might not yield additional verifiable detail at this stage. I planned to safely transition away from the majority of matters related to pricing (more on that in Part 3).
On the other hand, several responses highlighted “assertion vs. proof” gaps: It’s straightforward for experts reviewing their systems to assert accuracy (e.g., separate facility/professional splits, 340B markup application, or quantity confirmation), but without attached documentation or external references, a layperson or independent reviewer can’t verify it against standards or public benchmarks.
Medical billing and coding is highly technical. Since I am not an expert, these responses helped narrow our focus: which areas warranted deeper study (e.g., standard anesthesia billing splits, 340B program mechanics, typical supply markups) to better understand the context.
From a broader perspective, the pattern aligned with what we’d seen in the financial aid track: concise, lane-specific answers that address the query narrowly while avoiding broader discussion. Providers are under no obligation to exceed what’s required, and minimal but structured responses help maintain consistency and efficiency. A disciplined advocate views this not as an invitation to escalate emotionally, but as a cue to increase careful scrutiny: documenting gaps, refining questions, and building the parallel record methodically.
Then, what follows is one of the big challenges of being a consumer advocate, dealing with prolonged periods of silence. I want to point out that this is a valid strategy. They provided what they believe to be the final answer regarding these inquiries, and as such, any further discussion might be deprioritized. They are also under no statutory obligation to answer casual queries that don’t fall under their formal dispute process.
On the other hand, many institutions, not just healthcare providers, use this technique to allow disputes to naturally fizzle out. To their credit, it works for the vast majority of the time, especially in cases where patients believe that the cost in time to pursue the case far outweighs the perceived loss.
However, seasoned advocates counter this by maintaining a focus squarely on process while establishing clear timeframes in writing, always allowing extensions that provide a firm completion date. That way, if no response is given, all there is left to do is move on to the next step in the process.
The follow-up RFI sent out about a month later is more-or-less the same as the initial one, except I had to be more specific about the documentation we were seeking.
No response was received to the follow-up RFI within 30-day timeframe, even with an extra 12-day grace period to account for a national holiday. This just meant we were clear to send out one final RFI. This wouldn’t be necessary in most cases, but we had identified one additional issue over the course of continued investigation. To ensure that all matters were being presented up front, we sent this out and granted one last 30-day extension.
By the end of this process, more than 90 days have elapsed with 60 days of nonresponse.
At this point, it may not seem like a whole lot had been accomplished since the process began. I had sent a series of politely worded queries, we got one set of assertions, and silence beyond that point. However, I was hard at work building the administrative record through repeated, good-faith attempts at resolving the matter fairly and equitably.
The door was open the entire time to welcome additional feedback. If they had provided independently verifiable information, I would have had to accept it and notify Steve that those line items were no longer up for discussion.
So then came the point that I had to sit down with Steve and go over strategy. This was a precarious time for him because the bills from the earlier procedure were approaching the one-year mark. According to the industry-wide changes established in 2022, medical debts less than a year old would not be reported to credit bureaus. We had this working in our favor up to this point, but time was running out.
However, the next step of the process afforded some protections. Stay tuned for Part 3 to find out more.