This article is for educational purposes only and does not constitute medical, legal, or financial advice. Every family situation is different, and you should consult with appropriate professionals about your specific circumstances.

Medicare Billing Errors: How to Read and Dispute Medical Bills

Your father received an explanation of benefits in the mail that made no sense. Medicare approved a charge of $500 for a procedure that was supposed to be preventive and therefore free. Or you see a bill with the same charge appearing twice. Or your dad had lab work that seemed routine, but the bill shows three separate charges for what seemed like one test. You stare at the paperwork, trying to figure out if someone made a mistake or if this is just how Medicare billing works.

The frustration is real, and you're not being paranoid by thinking something might be wrong. Medicare billing is complex enough that errors happen regularly. Charges get duplicated. Services that should be free are billed as if they cost money. Procedures get coded incorrectly, so Medicare pays less than it should or the provider bills your parent for more than they should. The good news is that billing errors are fixable. Learning to read the paperwork and knowing how to challenge a charge you don't understand means your parent doesn't have to overpay.

The process isn't quick or automatic. It requires some persistence and willingness to ask questions. But the money saved is often worth the effort, especially if the mistake is a significant charge. You're not being difficult by questioning a bill. You're being a responsible family member protecting your parent's finances.

Reading the Explanation of Benefits

Medicare sends an explanation of benefits for every claim it processes. The EOB is dense, confusing, full of codes and abbreviations, and deliberately designed to be hard to understand. It's also the single most important document for understanding what Medicare approved, what it paid, and what your parent owes.

An EOB has several key sections. At the top is your parent's name, Medicare number, and the date the EOB was created. The next section lists the provider who submitted the claim—the doctor's office, hospital, lab, or imaging center where your parent received care. The claim number appears here, which is important for referencing the claim if you need to dispute it.

The actual claim details come next, and this is where you find the critical information. The line item shows the service code, the date the service was provided, a description of the service, the amount the provider charged, the amount Medicare approved, what Medicare paid, and what you owe. This line-by-line breakdown is the key to spotting errors.

The provider charged amount is what the doctor's office billed Medicare. This isn't what you pay. This is the amount they requested. Medicare approved amount is what Medicare decided is a reasonable charge for that service. The approved amount is usually less than what the provider charged because Medicare negotiates rates. What Medicare paid is the amount Medicare actually paid to the provider. This is typically 80 percent of the approved amount if your parent has Original Medicare. Your responsibility is the difference between what Medicare approved and what Medicare paid, which is your copay or coinsurance.

At the bottom of the EOB, it shows how much you owe the provider. This is the number that matters for your parent's out-of-pocket cost. If the EOB says you owe zero, your parent owes nothing. If it says you owe fifty dollars, your parent owes fifty dollars, not the provider's original charge of three hundred dollars.

This is the basic structure of every EOB. Once you understand the sections, you can use them to spot errors.

Common Billing Errors to Look For

Duplicate charges are the most obvious error to spot. If your parent had one lab test, there should be one charge for that test. If the EOB shows the same test code twice, with the same date of service and the same charged amount, that's a duplicate. Duplicates happen because office staff enter the claim twice, or because the claim gets resubmitted and both the original and resubmitted claim get processed.

Charges for services your parent didn't receive are another error category. If the EOB shows a charge for a procedure your parent is certain they didn't have, that's a mistake. This sometimes happens when a provider charges for an office visit every time your parent calls or when they charge for tests they ordered but never performed. Sometimes it's a provider billing for a service to someone else by accident, which is called billing fraud, but more often it's an honest mistake.

Charges for preventive services when those services should be free are common errors. Medicare covers certain preventive services at no cost to your parent if the service is performed as preventive care. If your parent had blood work as part of an annual wellness visit, that should be free. If the same blood work was ordered because your parent had a specific symptom, it might be billed as diagnostic rather than preventive, which means there's a copay. But if the service was preventive, it shouldn't have a charge.

Dates of service that don't match when your parent actually received care are a red flag. If the EOB shows a service on a date your parent wasn't seen, that's an error. This might be a data entry mistake. It might mean the charge was for a different patient. The date matters because billing windows have deadlines, and if the date is wrong, the appeal timeline might be wrong too.

Charges appearing with the wrong provider name suggest a claim got routed to the wrong place. If your parent saw Dr. Smith, but the charge says it's from Dr. Jones, that's a mismatch that needs correction.

The Difference Between EOB and Patient Bill

This is where people get confused, so it's important to understand clearly. The EOB is what Medicare sends to you and your parent. It tells you what Medicare approved and what Medicare paid. The patient bill is what the provider sends to you. It tells you what you owe.

These don't always match. An error on the EOB doesn't mean the patient bill is wrong, and an error on the patient bill doesn't necessarily mean the EOB is wrong.

Here's how they can disagree. Medicare sends the EOB to your parent showing that your parent owes fifty dollars in coinsurance. But the provider's bill shows your parent owes one hundred dollars. This disagreement might exist because the provider is trying to collect something Medicare says is the provider's responsibility, or because the provider hasn't processed the Medicare payment yet, or because the provider coded the claim differently than Medicare coded it.

The correct answer comes from the EOB, not the patient bill. Medicare.gov says that your parent's responsibility is what the EOB says it is. If the patient bill disagrees, your parent should contact the provider and explain what Medicare's EOB says. If the provider continues to bill incorrectly, that's a separate issue to take up with your parent's state's insurance commissioner.

How to Challenge a Charge You Believe Is Wrong

Start by asking the provider for clarification. Call the billing department at the office where your parent received care and say something like, "I received an EOB showing two charges for the same lab test on the same date. Can you explain why this charge appears twice?" The billing staff person might say, "We'll check our records and call you back." They might discover immediately that it was an error and they'll resubmit a corrected claim. Many errors get resolved at this step.

If the provider says they don't see any error, ask for an itemized bill. An itemized bill breaks down every charge separately and explains what each charge is for. A simple bill might say "Office Visit" for fifty dollars. An itemized bill says "Office Visit: Preventive Care" or "Office Visit: Sick Visit." The itemized bill helps you understand whether the charges are what you expected.

If the provider's itemized bill still doesn't make sense, and the provider won't acknowledge an error, you can submit a formal request to the provider to review the bill. In most cases, you put your request in writing, explain what you believe is wrong, and ask for a formal review. The provider's compliance officer or medical records department handles this kind of request. Some providers call this a "billing dispute" or "billing inquiry."

If the provider's review comes back and they still maintain the charge is correct, but you disagree, you can file an appeal with Medicare. You have 120 days from the date on the EOB to request that Medicare review the claim. To appeal, you submit a form to Medicare explaining why you believe the charge is wrong and what evidence supports your position. Attaching a copy of the EOB, your request to the provider, and the provider's response helps Medicare understand the dispute.

Medicare's appeal process is free. If Medicare's initial review supports your position, they can work with the provider to reduce or remove the charge. If Medicare doesn't support you, you can appeal that decision to a Medicare Administrative Law Judge. This process takes longer and requires more documentation, but it's available if you believe Medicare made an error.

Protecting Yourself from Future Billing Problems

Keep your own record of appointments and procedures. After each visit, write down the date, the provider you saw, what was discussed, what tests or procedures were ordered, and what the provider said the cost would be. If the provider said something is preventive and free, note that. This record is your reference point for checking against the EOB later.

Ask for itemized bills from providers, not just statements that show a total. Before you leave an appointment, ask whether there will be any charges. Ask what the charges are for. Ask whether your insurance will cover them. If the provider says there won't be a charge, ask them to note that in your record. This creates documentation of what you were told.

When you receive an EOB, spend ten minutes reading it and comparing it to what you expected. If the charged amount doesn't match what the provider said it would be, that's worth investigating. If a charge appears for a service you don't remember having, that's worth investigating. Catching errors early gives you more options for fixing them.

Catch errors within 120 days of the service date if possible. After 120 days, Medicare's appeal timeline has passed and you're limited in what you can do. Some providers also have time limits for billing disputes, often shorter than Medicare's 120-day window.

When to Get Help: Billing Advocates and SHIP

SHIP counselors can help you dispute bills and understand billing issues. Many states have their own patient advocacy organizations that specialize in billing error correction. These advocates know how to read EOBs, they know where the common errors happen, and they can advocate with providers on your behalf.

Some nonprofits specialize specifically in billing error correction. They might charge a fee if they recover money for you, but many will review a disputed bill free of charge. If a significant amount of money is at stake, these advocates can be worth the cost.

An attorney makes sense only if the disputed amount is large enough that the attorney's fees would be justified by the potential recovery. If the error is fifty dollars and an attorney charges two hundred dollars per hour, it doesn't make financial sense. If the error is five thousand dollars, an attorney might be worth the cost.

The System Isn't Perfect, But It's Fixable

Medicare billing is complicated, and errors happen. The system isn't designed to be easy for patients to understand. But errors are correctable. When you find a billing mistake, you have the right and the option to challenge it. It takes time and persistence, but the money saved is real. More importantly, when you catch an error on your parent's bill and get it corrected, you're protecting your parent's financial security and also protecting the integrity of the Medicare system. Every error you report and correct makes the system a little cleaner for everyone.

How To Help Your Elders is an educational resource. We do not provide medical, legal, or financial advice. The information in this article is general in nature and may not apply to your specific situation. If you are concerned about billing errors, contact a SHIP counselor, your provider's billing department, or consult with a billing advocate for guidance and support.