Every dispute scenario, with the federal law behind it.

Upcoded ER visit — when the level on the bill doesn't match the chart

ER visits billed at a higher complexity level than the medical record supports are the most common billing-error pattern in the country. Federal coding rules let you dispute the level.

CMS Internet Only Manual, Pub. 100-04, Ch. 12, §30.6.1

Unbundled charges — when one procedure gets billed as several

Federal coding rules (NCCI edits) explicitly prohibit billing certain combinations of CPT codes together. When you see them on your bill, the federal benchmark gives you grounds to dispute.

42 CFR §414.40 / CMS NCCI Policy Manual

Wrong place-of-service code — facility billing for a non-facility visit

Place-of-service codes determine whether Medicare and most insurance pay the higher facility rate or the lower non-facility rate. A code mismatch can inflate a bill substantially.

42 CFR §414.22, CMS Place of Service Code Set

Modifier-25 abuse — separate E/M billed alongside a procedure

Modifier 25 lets a provider bill an office visit alongside a procedure on the same day, but only when the visit is a 'significant, separately identifiable' service. The OIG has repeatedly flagged inappropriate use.

CMS Internet Only Manual Pub. 100-04, Ch. 12 §30.6.6.B / NCCI Policy Manual Ch. 1 §G

Observation vs. inpatient — billed under the wrong status

Observation status looks like an inpatient stay to the patient (same room, same care) but bills under outpatient rules — which can mean much higher cost-share for Medicare beneficiaries and a denied SNF benefit.

42 CFR §412.3 / NOTICE Act (Pub. L. 114-42)

Annual physical billed as a sick visit

Preventive visits (annual physicals, well-child checks) are required by the ACA to be $0 cost-share when in-network. When the same visit gets coded with a diagnostic code, you may owe a copay or coinsurance you weren't expecting.

ACA §2713 (PHSA §2713) / 45 CFR §147.130

Anesthesia time billed in excess of documented minutes

Anesthesia bills are calculated by time units. Each 'unit' is 15 minutes of documented anesthesia time, plus base units for the case complexity. Time-unit inflation is a documented audit pattern.

CMS Internet Only Manual Pub. 100-04, Ch. 12 §50

Duplicate charges — same service billed twice on the same bill

When the same service appears on a bill more than once — sometimes under slightly different code variants — federal billing rules give patients clear grounds to ask for the duplicate to be removed.

31 USC §3729 (FCA) / 42 CFR §424.32 (claim accuracy)

Phantom charges — services billed that you didn't receive

Charges for services, supplies, or medications you never actually got are some of the most common patient-side billing complaints. Federal consumer-protection law gives you the right to challenge them.

31 USC §3729 (FCA) / state UDAP statutes

Facility fee from a 'provider-based' clinic without prior notice

When a hospital owns a doctor's office, the visit can bill twice — once for the doctor and once as a facility fee. Federal disclosure rules require advance written notice.

42 CFR §413.65(g)(7)

Saline IV markup — when a $3 bag bills at $300+

Normal saline (sodium chloride 0.9%) is one of the most-marked-up items in hospital chargemasters. The Medicare-allowed amount and the NADAC pharmacy acquisition cost are publicly published; the gap to chargemaster is documented.

42 CFR §447.502 (NADAC) / 42 CFR §414.1 (PFS)

Surgical implant billed as a separate pass-through charge

Many surgeries include the cost of the implant in the procedure code. When the implant is billed separately ('pass-through'), the math should add up to the surgery package, not exceed it.

42 CFR §412.87 (NTAP) / NCCI Policy Manual Ch. 1

Surprise billing — out-of-network charges at an in-network facility

The No Surprises Act (2022) protects patients from out-of-network bills for emergency care and from out-of-network providers at in-network facilities. Federal law caps your liability.

Public Law 116-260, Division BB / 45 CFR §§149.1–149.510

Good Faith Estimate — when the bill is much higher than what they quoted

The No Surprises Act requires healthcare providers to give uninsured/self-pay patients a Good Faith Estimate. If the bill exceeds the estimate by $400+, you have federal dispute rights.

45 CFR §149.610 (GFE) / §149.620 (PPDR)

ER bill from out-of-network provider — federal protection at any hospital

The No Surprises Act mandates that emergency services be billed at in-network rates, regardless of which hospital you went to or who treated you.

PHSA §2799A-1 / 45 CFR §149.110

Ambulance balance bill — federal NSA gap, but state laws often apply

Ground ambulances are explicitly excluded from the federal No Surprises Act. But many states have closed the gap with their own laws — Colorado, Nevada, West Virginia, and more.

Colorado HB-19-1174 / Maryland HB-1005 / Nevada AB-469 / others

Charity care — your right to financial assistance at non-profit hospitals

ACA §501(r) requires non-profit hospitals to offer free or discounted care to patients meeting income criteria. Most patients never apply because most never know.

26 USC §501(r) / 26 CFR §1.501(r)-3 to -6

Presumptive eligibility — automatic charity-care qualification

Some non-profit hospitals' Financial Assistance Policies grant automatic charity-care eligibility to certain categories of patients without requiring an income application.

26 CFR §1.501(r)-4(b)(4) / FAP-implementation guidance

Apply for Medicaid retroactively — covers up to 3 months back

Federal Medicaid rules allow retroactive coverage for up to 90 days before the application month. If your bill is from that window, Medicaid can pay it.

42 USC §1396a(a)(34) / 42 CFR §435.915

Sliding-scale discount at for-profit hospitals

For-profit hospitals don't have to offer charity care under §501(r), but most have a 'self-pay discount' or 'sliding scale' policy. They just don't advertise it.

Hospital-specific Self-Pay Discount Policy / Financial Hardship Policy

Insurance denied for 'not medically necessary' — your appeal rights

ERISA and ACA give every insured patient the right to appeal denied claims. Internal and external review processes are mandatory; insurers must follow specific timelines.

ERISA §503 (29 USC §1133) / ACA §2719 (42 USC §300gg-19)

Service denied because prior authorization wasn't obtained

When the doctor's office didn't get prior auth and your insurance denies the claim, the hospital often bills the patient. Federal rules and many state laws push that liability back to the provider.

ERISA §503 / state UDAP / state prompt-pay laws

Step therapy denied — must try cheaper drug first

'Step therapy' or 'fail first' rules require trying a lower-cost drug before insurance covers a more expensive one. Federal and most state laws give patients a way to bypass when medically necessary.

42 CFR §423.578(a) / state step-therapy laws (varying)

Medicare Advantage denied a service Original Medicare would cover

Medicare Advantage plans (Part C) must cover everything Original Medicare covers — and OIG has flagged repeated patterns of inappropriate denials. The MA appeal process exists for exactly this.

42 CFR §422.566 / OIG MA Audit Reports

Hospital won't send an itemized bill — your federal right to one

HIPAA §164.524 gives every patient the right to a copy of the bill in itemized form. If a hospital sends only a summary, you can demand the full itemization.

HIPAA §164.524 / 45 CFR §164.524

Get your medical record — 30-day federal right

HIPAA gives every patient the right to a copy of their medical record within 30 days. The chart is the foundation of any bill review or appeal.

HIPAA §164.524 / 45 CFR §164.524

Debt validation letter — the FDCPA tool every patient should know

When a medical debt is sent to collections, federal law gives you 30 days to demand validation. The collector must prove the debt is yours and accurate.

FDCPA §1692g / 15 USC §1692g

Negotiating a medical bill — the settlement offer

Many hospitals have written self-pay discount policies that may apply on request. Federal law doesn't require it, but written policies are common.

Hospital self-pay discount policies (vary by hospital)

Medical debt on a credit report — current consumer protections

All paid medical debt has been removed from credit reports since 2023. Unpaid medical debt under $500 doesn't get reported. The CFPB has proposed eliminating medical debt from credit reports entirely.

FCRA §623 / Equifax-Experian-TransUnion 2022/2023 policy update

Medical debt past the statute of limitations

Each state sets a window — typically 3 to 10 years — after which a creditor can no longer sue to collect a debt. The debt itself doesn't disappear, but the legal lever to force payment does.

Vary: 3-10 years by state; FDCPA §1692e disclosure rules