Every bill is negotiable. Every denial can be appealed.
The system counts on you not knowing this. They send official-looking bills and hope you pay. They deny claims and hope you give up. They use complexity as a weapon, betting that you'll surrender before you figure it out.
Most people do. That's why it works.
But the people who push back — who call, who question, who appeal — get different results. Bills get reduced. Denials get overturned. Payment plans get extended. Debt gets forgiven.
This is how you fight.
The Mindset Shift
Before tactics, you need to understand something:
You are not begging. You are negotiating.
The provider wants to get paid. The insurance company wants to close the claim. Collections wants to recover something. Everyone has an incentive to make a deal.
When you call to negotiate, you're not asking for charity. You're offering a resolution. You have something they want — payment, closure, an end to the back-and-forth. That has value.
They need you to pay. You need a fair price. That's a negotiation, not a favor.
Before You Call — Preparation
Never call unprepared. Gather everything first.
Documents you need:
The bill (every version you've received)
Your Explanation of Benefits (EOB) from insurance
An itemized bill (request one if you only have a summary)
Your insurance policy (know your deductible, out-of-pocket max, co-insurance)
Notes from any previous calls (dates, names, reference numbers)
A calculator and notepad
Research before calling:
What does Medicare pay for this service? (Use Medicare's Physician Fee Schedule lookup)
What's the fair market rate? (Use Healthcare Bluebook or FAIR Health)
What's the hospital's cash price? (Check their price transparency page)
What financial assistance policies does this provider have?
Know your numbers:
What's your out-of-pocket maximum? Have you hit it?
What have you already paid this year toward your deductible?
What can you actually afford to pay — monthly, total?
Negotiating Bills — The Script
When you call, be calm, polite, and persistent. The person on the phone isn't your enemy — they're just doing a job. But they also have authority to make deals.
Opening:
Get to someone with authority. Front-line staff may not be able to negotiate.
If the bill seems wrong:
Review it. Look for duplicate charges, services you didn't receive, or codes that don't match what happened.
If the bill is correct but too high:
Wait. Let them make the first offer.
If they resist:
This isn't a threat — it's a statement of reality. They'd rather make a deal than send you to collections and get pennies on the dollar.
Closing the deal:
Always get it in writing. A verbal agreement means nothing if they send you to collections later.
The Cash Pay Gambit
Sometimes the best move is to skip insurance entirely.
When to offer cash:
- • Your insurance has denied the claim
- • You haven't hit your deductible and the bill is less than the deductible
- • The cash price is lower than your co-insurance would be
- • You're uninsured
The script:
Why it works:
Cash is attractive to providers because:
- • No billing back-and-forth with insurance
- • No risk of denial
- • Immediate payment
- • No collections risk
They'll often discount 20-50% for immediate cash payment. Sometimes more.
Payment Plans — Setting Your Terms
If you can't pay in full, a payment plan keeps you out of collections while you chip away at the balance.
Key point: You propose the terms, not them.
The script:
If they counter with a higher amount:
What to confirm in writing:
Monthly payment amount
Total balance
Interest rate (should be 0%)
Length of plan
What happens if you miss a payment
Confirmation they won't send to collections while you're paying
"I have several payment plans running right now. The system accommodates this — they'd rather get something than nothing."
Appealing Insurance Denials
Insurance companies deny claims hoping you won't appeal. But appeals work — studies show 40-60% of appeals are successful.
Types of appeals:
Internal Appeal: You ask the insurance company to review their decision. Required before external appeal.
External Appeal: An independent third party reviews the decision. Insurance company must comply with the result.
Common denial reasons and how to fight them
"Not Medically Necessary"
They're claiming you didn't need the treatment your doctor ordered.
How to fight:
- • Get a letter from your doctor explaining why it was necessary
- • Include clinical notes, test results, anything supporting the decision
- • Cite medical guidelines or studies supporting the treatment
- • Point out that a doctor examined you; they didn't
Script:
"Out of Network"
They're saying the provider wasn't in their network.
How to fight:
- • If it was an emergency, cite the No Surprises Act
- • If you weren't informed the provider was out of network, document that
- • If the in-network provider referred you, that matters
- • Request they apply in-network rates
Script:
"Prior Authorization Not Obtained"
They're saying approval wasn't obtained before the service.
How to fight:
- • If it was an emergency, prior auth isn't required
- • If the provider was supposed to obtain it, that's between them and the provider — not your problem
- • If you did get prior auth, provide the reference number
Script:
"Experimental or Investigational"
They're claiming the treatment isn't proven.
How to fight:
- • Provide studies showing efficacy
- • Show FDA approval if applicable
- • Cite medical society guidelines recommending it
- • Get a letter from your doctor with clinical rationale
"Timely Filing"
They're claiming the provider submitted the claim too late.
How to fight:
- • This is between the provider and insurance — not your responsibility
- • You shouldn't be billed for their administrative failure
Script:
The Appeal Letter Template
External Appeals — The Nuclear Option
If your internal appeal is denied, you can request an external appeal. An independent reviewer — not employed by the insurance company — reviews your case. Their decision is binding.
How to request:
Your denial letter must include instructions for external appeal. Follow them exactly. There are deadlines — usually 4 months from the internal appeal denial.
Why it works:
External reviewers aren't paid to deny claims. They're paid to make fair decisions. And insurance companies know that losing external appeals looks bad and can trigger regulatory scrutiny.
Most people never get to external appeal because they give up at internal. Don't give up.
Disputing Bills — When Something Is Wrong
If a bill is incorrect — duplicate charges, services not rendered, wrong amounts — don't just negotiate. Dispute.
The script:
Follow up in writing:
Send a letter documenting your dispute. Keep a copy. Send it certified mail with return receipt so you have proof they received it.
If they won't correct it:
- • File a complaint with your state insurance commissioner
- • File a complaint with the hospital's patient advocate
- • For billing errors, consider a medical billing advocate (they take a percentage of savings)
Collections — It's Not Over
If a bill goes to collections, you still have options.
Validate the debt:
Within 30 days of first contact, send a debt validation letter. They must prove the debt is yours, the amount is correct, and they have the right to collect it.
Script:
Negotiate with collections:
Collections agencies buy debt for 10-20 cents on the dollar. They'll take far less than the original amount to settle.
Script:
Know the new rules:
- • Medical debt under $500 can't go on your credit report
- • Paid medical debt must be removed from credit reports
- • Medical debt is weighted less heavily in credit scoring
When to Get Help
Sometimes you need reinforcements.
Patient advocates:
Many hospitals have patient advocates who can help navigate billing disputes. Ask for one.
Medical billing advocates:
Professionals who fight bills for a living. They usually take 25-35% of whatever they save you. Worth it for large, complex bills.
State insurance commissioner:
If your insurance company isn't following the rules, file a complaint. Regulators can force them to comply.
State attorney general:
For billing fraud or deceptive practices, your state AG's consumer protection division may help.
Legal aid:
If you're being sued for medical debt or facing bankruptcy, legal aid organizations may provide free help.
The Numbers That Matter
of insurance appeals are successful
of medical bills contain errors
or more can often be negotiated off a bill
on the dollar is what collections pays for debt
The system is betting you won't push back. The numbers say you should.
The Bottom Line
You have more power than you think.
Every bill is an opening offer. Every denial is the first "no," not the last word. Every collections threat is a negotiation tactic.
The people who get crushed by medical debt are the ones who pay the first number they see and accept the first denial they receive. The people who survive are the ones who call, question, appeal, and negotiate.
Be the second kind.
They're counting on you to give up. Don't.
Next Up
Assistance Programs
Charity care, pharma programs, foundations, and how to access them.