The hospital was starting to send ugly letters about us paying the entire bill.

When Susan May’s son was a year old, he had a heart transplant.  

With no health insurance, the family, with four children aged 7 and under, was left with a hospital bill of $89,000 a seemingly impossible amount of medical debt.

“With the help of family and friends we had raised around $20,000 through a fund for children with transplants,” said May, now 56, who lives in Georgia in the US. “Then we started paying out of pocket something like $50 per month.”

But it wasn't enough. “By the time two years had gone by, the hospital was starting to send ugly letters about us paying the entire bill,” she recalled.

After much research and many phone calls, May discovered a patient assistance group at the hospital that could vote to lower a patient bill. May wrote to the group detailing her payment efforts, and a month later she received a letter stating that her son’s bill — at that time about $67,000 — was cleared. “It sounds simpler and less stressful than it really was,” said May, whose son is now 26.

May was lucky to have her medical debt dismissed, but many others in the US and countries where treatment isn’t publicly funded aren’t as fortunate. “It has been a big problem for quite some time,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation in the US. “Survey data indicate anywhere from one in four, to one in three Americans have trouble paying medical bills, and that most people in that situation have health insurance.”

In some countries, medical debt isn't a big issue, such as the UK where treatment is covered under the publicly funded National Health Service or in Canada where care is funded by the government as well. But in places like the US it can be financially devastating. Indeed, the issue is significantly worse in the US than anywhere else in the world.

In one survey from the US Commonwealth Fund, a private nonpartisan foundation, 23% of US adults had serious problems paying medical bills or couldn’t pay them at all. The next-highest country on the scale was France, where 13% of adults struggled to pay medical bills, followed by 6% or fewer in the UK, Sweden and Norway. (Even in countries where care is publicly funded, people sometimes owe co-payments or a percentage of costs, and some use private insurance instead of, or in addition to, the public system.) Additionally, 41% of US adults spent $1,000 or more out of pocket for care in the past year, the highest of all 11 countries in the survey.

If you’re burdened by medical debt, here are some tips on managing the big numbers.

What it will take: You’ll need to be organised, persistent and willing to research medical costs. “Sometimes mistakes do happen, and sometimes there are honest disputes between a consumer and an insurer about what the policy should cover,” Pollitz said. “It always pays to ask.”

How long you need to prepare: To correct a bill or negotiate a large balance, you need enough time to gather supporting documents and do some research, but don’t take too long.

“Hospitals and doctors want to get paid promptly,” Pollitz said. “They usually want to be paid within about 90 days.”

Do it now: Gather your paperwork. You’ll need an itemised bill, an explanation of benefits or coverage from your insurer and a copy of your medical record. That’s because the first step is to check for errors, which are stunningly common. More than 80% of medical bills in the US contain errors, according to the Medical Billing Advocates of America. Look for duplicate charges or services billed that you never actually received. Before you make any calls, lay out and examine all of this.

Check online for comparison. If your bill is accurate but still seems high, check sites such as or in the US to get reasonable price estimates for a procedure or service in your area. If your charges seem expensive, consider asking your insurer if the claim was processed correctly.

“It’s possible that it was priced as an out-of-network claim when it should have been priced as in-network,” said Maureen Lamb, owner and founder of Medical Bill Support, a medical bill advocacy company in New Hampshire in the US. “You really want to drill down with your insurance company.” Find out, for instance, whether the service was not covered or not pre-authorised — and why.  

Look into financial assistance. Once you’re working with an accurate bill, call the hospital or provider and ask to speak to the billing office — then ask what help might be available if you can’t pay your bill in full. Depending on your income, you may be eligible for financial assistance or charity care. Also ask if there is a patient assistance program. If so, you may be able to sit down with a social worker who will help you figure out how to pay your bills.

“They’ll actually go through the bills with you,” said Michelle Katz, healthcare consumer advocate and author of Healthcare Made Easy. They may also be able to arrange assistance programs for expensive medication.

Make a deal. Although providers don’t advertise this fact, many bills are negotiable. You might be able to work out a payment plan, or you can offer to pay cash and settle it for less now.

“Sometimes a hospital or provider’s office will give a prompt pay discount if you can pay… within 30 days,” Lamb said.

Work your way up the chain. If the person you’re working with can’t adjust your bill, ask to speak to their supervisor.

“Ask the person you’re talking to, ‘Do you have the authority to provide a discount?’” Lamb advised. “Sometimes they want to be helpful but they aren’t really able, so you have to ask for someone higher up in the level of management, like a billing manager or director of patient accounts.”

Keep good records. Write down the full name of each person you speak to, when you spoke to them and what you discussed.

Consider hiring help. Depending on the size of the bills and your ability to pay, it might be worth hiring a billing advocate to fight on your behalf.

“When the bills start coming in, most of the time that means you’re pretty sick,” Pollitz said. “That’s a really rough time to expect people to start doing research and collecting data and writing letters. It is not an intuitively easy process for consumers.” Many advocates offer the ability to pay them by the hour (anywhere from $100 to $200) for their work or to pay only a percentage of the amount they get taken off your bill, typically 25% to 35%.

Do it later: Follow up in writing. “If you’re just not getting anywhere on the phone, follow up with a letter and document the conversations that you’ve had and what you’re trying to ask for,” Lamb said. “It’s best to do this earlier in the process as opposed to later.”

A hospital or provider will be more willing and able to work with you when the bill is still in house and not with a collection agency.

Get it in writing. “If the dispute has been resolved, ask for a statement declaring that your bill has been reduced,” said Matt Moulakelis, co-founder of US billing advocate company Dispute.

Do it smarter: Be nice. The people on the other end of the line don’t have to help you — but they might be more willing to do so if you’re polite and courteous.

“Most people who call us are really stressed about their high medical bills,” Lamb said. “One of my first clients screamed at me over the phone, and that is something people absolutely can’t do. It can really make a difference in terms of how calm and professional you are.”

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