If You Have a Bill
California's Hospital Fair Pricing Act limits the amount hospitals can charge self-pay patients.

If your insurance company won’t pay

If you have health insurance and believe that all or part of your hospital bill should be paid for by your insurance company, but the hospital is billing you, there are steps you can take:

  1. Call the doctor or hospital and make sure they have billed your insurance company. 
  2. Call your insurance company's Member Services phone number on your insurance card or paperwork, and find out why your insurance company has not paid the bill; try to work it out with them.
    • If the doctor or hospital is billing you because your insurer didn't pay as much as the doctor wants, you are being "balance billed," an increasingly common (and sometimes illegal) practice that unfairly puts the consumer in the middle of a billing dispute between the health insurer and the doctor or hospital.  In October 2008, California established rules to restrict balance billing for emergency services.  These rules protect consumers with coverage through HMOs, Blue Cross PPOs and Blue Shield PPOs against billing disputes between out-of-network emergency doctors and their insurance companies.  Consumers with coverage through PPOs sold by companies other than Blue Cross and Blue Shield, or other kinds of health benefits such as high-deductible plans and limited benefit plans, are NOT protected by these rules. 
    • If your insurance paid only a tiny part of the bill, you may have junk insurance.  Visit our Public Policy page and scroll down to learn more about our efforts to restrict the sale of junk insurance. 
  3. If you cannot work it out with your insurance company, file a grievance with them immediately, because this will prevent the hospital from suing or reporting you to a credit agency until a final determination is made by your insurance company. Look in your insurance documents or health plan booklet (called Evidence of Coverage or Summary of Benefits) to find out how to file a grievance in writing. You can call your plan's Member Services and ask for this information. If your problem is urgent, meaning there is a serious threat to your health, your health plan must give you a decision within 3 days.  If your problem is not urgent, your health plan must give you a decision within 30 days.
    1. If you have an HMO, or a PPO through Blue Cross or Blue Shield, and you disagree with your health plan's decision or if you have not gotten the plan's decision within 30 days or within 3 days if the problem is urgent, contact the Department of Managed Health Care Help Center or call 1-888-466-2219 to file a complaint or ask for an Independent Medical Review (IMR).  In 2005, about one-third of health plan denials were overturned through IMR and consumers received services that would otherwise have been denied.
    2. If you have fee-for-service insurance or a PPO through an insurance company other than Blue Cross or Blue Shield, contact the California Department of Insurance or call them at 1-800-927-4357 to file a complaint or ask for an Independent Medical Review.
    3. If your coverage is through Medi-Cal or Healthy Families, see the Health Consumer Alliance Medical Debt Fact Sheets #1 and #2 for how to file an appeal.

The hospital may not sue or report you to a credit agency until your insurer makes a final determination. 

Keep copies of any letters and other documents you send so you have proof that you sent them. Fax letters and documents and keep the fax delivery confirmation as proof that the provider got your fax. If you don't have access to a fax machine, you can send your letter certified mail and ask for a return receipt. The return receipt is your proof that the provider got your letter.

Write down the name and telephone number of anyone you talk to about your bill, and the date of the conversation.