Unexpected Medical Bills? Know Your Rights on Pre-Authorization & Insurance

In the U.S., a provider generally cannot bill you for an expensive procedure they never verified with your insurer. Here’s how the process works and what to do if you receive a surprise bill.

Standard Billing Workflow

1. Estimation & pre-authorization: The provider estimates costs and submits them to your insurer for pre-approval, confirming coverage and your financial responsibility (copay, coinsurance, deductible).
2. Consent & billing: You sign consent forms acknowledging estimated charges. After the procedure, the provider bills both you and your insurer.
3. Insurance review: The insurer evaluates the claim against your plan and pays the provider or reimburses you.
4. Your responsibility: If the provider skipped pre-authorization and your insurer denies coverage, you have the right to dispute the charges.

Steps to Resolve a Surprise Bill

1. Contact your insurer for a written coverage determination on the procedure.
2. Share that documentation with the provider’s billing department and request a correction.
3. If unresolved, file a complaint with your state insurance department or medical billing regulator.
4. Review your Explanation of Benefits (EOB) to verify charges match your coverage.

Keep records of all communications and documents to support your case.