This is a tough topic to broach because not only is it common, but many healthcare providers tend to be very opaque about the way your charges show up on an itemized statement.
To the average person, a charge that seems overinflated or out of place could easily be explained as a legitimate circumstance.
When charges can’t be explained, I know from professional experience that providers will deny, deflect, and defend.
This leads to a great amount of complexity and opacity. The average patient will not know what charges are legitimate or not unless they consult a billing expert or patient advocate outside the organization.
Truth be told, I’m not a billing expert either. However, my advocacy practice is centered around early and amicable solutions.
Disclaimer: the process I’m about to describe does not cure instances of malpractice or questionable medical necessity. That requires legal assistance that I am not qualified to give.
What I do, instead of making accusations out of the gate, is point out that some charges simply look unusual and ask for specific feedback from the provider. This is called a Request for Information, or RFI for short.
Pre-work
Before you start work on your RFI, you’ll need to first take a look at your itemized billing statement. If you need a copy, I break down how to obtain one here.
You are looking for primarily overcharges or overly-inflated charges. However, it wouldn’t hurt to allow an AI model to analyze it. Although output from any AI model could contain errors, those instances tend to be the easiest matters for healthcare providers to clear up.
If you find anomalies, you’ll need to list them by account, CPT code, charge, and amount.
You will also need an explanation of benefits (EOB) from insurance. While the itemized statements will give you an overall breakdown of how much the provider is asking for on a line-by-line basis, that level of granularity does not apply to patient responsibility. You will need to compare the two to figure out exactly what line items your responsibility comes from.
In many instances, such as with labs and pathology charges, the sticker price that providers attach to these are quite shocking. However, many insurance companies heavily cover down on these.
Point being: you can safely drop an issue where patient responsibility only amounts to a few bucks. In fact, pursuing any charge under $100 yields diminishing returns.
For items that appear overpriced, you will need to determine the CMS and regional benchmarks for that item. Regional benchmarks are important because they show the variance of pricing within your local area. If several other local providers charge around the same amount for the same service, the issue can be safely dropped.
CMS benchmarks are a different story, however. These are useful because, where available, they provide a measurement for service within the United States. If you are a private insurance holder, you can reasonably expect to pay 2-3 times the Medicare/Medicaid rate for a specific service. Any charges over that threshold should be more closely investigated.
The Structure of an RFI
These letters need to be brief, direct, and to the point while also being courteous and respectful. There is no room for bluster or any language that can appear threatening. You are simply asking a series of polite questions. Make your introduction and final paragraph straight to the point.
Here is where your pre-work will pay off. After analyzing your itemized billing statement, your Insurance EOBs, and CMS/regional benchmarks, you should have a list of accounts/CPT Codes/Charges that you need more information on. Each item should follow a Description – Concern – Request format. Your Description will contain the short title for the procedure, the account number, CPT code, and the amount charged. The concern simply outlines what makes the charge appear irregular. Again, this needs to be done in non-accusatory language.
Finally, you make a request on how you want the concern to be addressed. If you simply ask a question like “can you confirm if this is correct?”, the answer will always be “yes” whether that is factual or not. Yes/no questions will close the door on the issue immediately.
The standard you are looking for is documented proof that is independently verifiable. In other words, you need something that you, me, or Jim who lives down the street can easily take a look at and verify to be true. Otherwise, they are operating off of assertions.
However, you can’t just simply ask for “proof”. You have to be specific about what documents you are asking for.
Unfortunately, this becomes sticky because many providers claim this data is proprietary. Even when it isn’t they tend not to share data that is propriety-adjacent for a number of reasons.
While the proprietary information claim made by many providers is quite broad, the application that many legal experts recognize is more narrow. You may not be able to ask for a whole internal policy, but you may ask for an excerpt with redactions. You may not be able to ask for a chargemaster, but you may ask for the portions that are specifically relevant to your case. Heavy redactions are both expected and reasonable.
That is ultimately why consumer advocates like myself come into play–we know where the line is and are professionally trained to ask for documentation in a way that cannot be reasonably construed as demanding proprietary data.
Their Response
While there are many videos and shorts out there that claim “80% of all hospital bills contain errors”, these errors exist in a spectrum. A large part of that 80% usually fall under single line-item errors that can be cured or written off without much issue. This might translate to a few hundred dollars of adjustments at best. It is less than 20% where multiple or exceptionally flagrant errors exist.
More often, the documentation and paperwork that is required to substantiate the charge according to federal regulation is where many providers are found lacking.
The way you will need to gauge where on the spectrum your case lands on is by the provider’s response.
If you don’t get a response or you get a largely defensive one full of assertion statements without proof or other language that appears as deflection or stonewalling, chances are that there were errors in the charges or with how the charges were documented. One or more the charges may not survive scrutiny if audited.
If the response seems at least semi-plausible and they appear to be reasonably cooperative, then you are looking at the cleaner side of the spectrum.
Either way, it’s rare for a provider to be entirely cooperative. Patient Relations teams are trained to hold the line against potentially hundreds of consumer complaints they receive a year. Their responses are often canned, approved by risk/compliance, and provide little detail.
By submitting an RFI with non-accusatory language and clear, objective concerns, you establish both credibility and deliver a message that you will not walk away without an answer. This puts you above 90% of the complaints that land on the Patient Relations desk.
A trained consumer advocate can assist you in interpreting these responses, preparing documentation, and determining a way forward.