Out-of-network surprise charges, balance billing, coding errors, duplicate billing, denied claims, and No Surprises Act violations — we draft a letter citing 42 USC 300gg-111, the No Surprises Act, and ERISA § 502(a), route it through CMS, and track escalation until the bill is corrected or withdrawn.
Patient received emergency or involuntary out-of-network care and was billed at out-of-network rates for services covered under their plan.
Cite: No Surprises Act 42 USC 300gg-111 — patient owes only in-network cost-sharing.
Provider bills the difference between the full charge and the insurer's allowed amount after a surprise-bill scenario.
Cite: No Surprises Act § 9816 (employer plans) / 42 USC 300gg-111 (individual/group) — balance billing is prohibited.
Wrong CPT/ICD-10 code applied (upcoding, unbundling, or a modifier stripped), inflating the charge or triggering a false denial.
Cite: 45 CFR 162 (HIPAA transaction standards) + payer contract — request itemized bill + corrected claim.
Same service, date, and provider billed twice; common after a claim resubmission or system conversion.
Cite: 42 USC 1395nn / 18 USC 1347 (False Claims exposure) — insurer must reverse the duplicate on written demand.
Insurer denied a covered service citing lack of medical necessity, wrong network tier, or a missing prior auth that the plan never required.
Cite: ACA § 2719 / 45 CFR 147.136 — internal + external appeal rights, 30-day urgent / 60-day standard deadline.
Provider or facility billed above allowed amounts, failed to give good-faith cost estimates, or applied an out-of-network rate where the Act prohibits it.
Cite: No Surprises Act (42 USC 300gg-111) — file with CMS No Surprises Help Desk.
No. Under the No Surprises Act (42 USC 300gg-111), you owe only in-network cost-sharing for emergency services and certain non-emergency services at in-network facilities, regardless of provider network status.
Under ACA § 2719 and 45 CFR 147.136, you have the right to an internal appeal (30 days urgent / 60 days standard) and then a binding external review by an independent organization. Our letter cites both timelines.
Request the itemized statement in writing (hospitals must provide one under most state laws) and identify the duplicate by date, CPT code, and dollar amount. A formal written dispute triggers the insurer's obligation to investigate and reverse the charge.
The escalation path is: (1) CMS No Surprises Help Desk for NSA violations, (2) your state Department of Insurance for coverage disputes, (3) DOL Employee Benefits Security Administration for ERISA plans, then (4) small-claims court for amounts within local limits. We track through each tier.
Free, federal-law-cited, and tracked through CMS and your insurer until the bill is corrected.
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