In a 2022 study, the bureau found that roughly 20% of U.S. households report that they have medical debt, with collections appearing on 43 million credit reports. As of the second quarter of 2021, 58% of all bills in collections on credit records were medical bills.

Medical debt affects households unevenly, too, according to the agency. Past-due bills are more prevalent among Black and Hispanic people than white and Asian people, and medical debt is more common in the Southern U.S., in part because states in that region did not expand Medicaid coverage.

While the process of fighting high medical bills can be time-consuming and frustrating, advocates stress that patients shouldn’t be intimidated by the system. If you’ve received a surprise medical bill, here’s what you should know:

Always see if you qualify for charity care

When Luisa, 33, received a medical bill for over $1,000 after an emergency hospital visit for a viral infection, she was able to have the whole amount covered by the hospital after appealing to their financial assistance policy.

“At first I thought it was just a cold, but it turned out to be something I needed specific medication for,” said Luisa, who asked to be identified only by her first name due to privacy concerns. “It was really bad by the time I went to the ER.”

Luisa had heard about the patient advocacy organization Dollar For thanks to a viral video, and she filled out the nonprofit’s online form after receiving her surprise bill. The organization contacted the hospital, which was based in central Florida. Eventually, the hospital contacted Luisa directly to let her know she did in fact qualify for financial assistance. Even though she had already paid a portion of the costs with a credit card, Dollar For was able to get those payments refunded.

Laws governing hospital charity care require that nonprofit hospitals lower or write off bills for individuals, depending on household income. To determine if you qualify, you can simply Google the hospital along with the phrase “charity care” or “financial assistance policy.” Dollar For also provides a simplified online tool for patients to see if they qualify.

“Federal law requires hospitals to have these programs to keep their tax-exempt status,” said Jared Walker, CEO of Dollar For. “If you’re within their income range, they will write off, waive, forgive, or reduce your bills.”

Even if you’ve already been paying off medical debt, the hospital will be required to refund the payments you’ve made, he said.

“It was my first time going through something like that,” Luisa said. “I tried to be an informed consumer and ask questions when I was in the hospital about the costs, but obviously it’s hard when you’re sick in the emergency room.”

Appeal to the No Surprises Act

While protections against surprise bills have long existed for those who have Medicare, Medicaid, and Tricare, laws are now also in place for those with private or marketplace insurance.

The federal No Surprises Act covers people who have insurance through their employers, the marketplace, or individual plans. It says that insurance companies must reasonably cover any out-of-network services related to emergency and some non-emergency medical care. That means that if you’re being charged more than you’re used to or expect when you receive in-network services, that bill may be illegal.

To challenge any bill covered under this law, you can use the free help desk and hotline of the Centers for Medicare and Medicaid Services. Many states also have free consumer assistance programs to help with disputes and insurance questions. You can always contact the medical billing department of any hospital in writing to say that you believe a bill is in violation of the No Surprises Act and ask the hospital to deal directly with your insurance company.

“The complexity of the system itself is as big a problem as affordability,” said Kaye Pastaina, who heads research on patient protections for KFF, a nonprofit health policy organization. “A lot of it is from the fragmented system and complex rules, but also lack of awareness about existing protections that are a part of federal law that might help.”

Ask for an itemized bill

Even if you don’t qualify for charity care or you’re not sure your bills are covered by the No Surprises Act, you may be able to reduce the charges.

Medical billing is notoriously byzantine and rife with errors. Anytime you receive a bill, ask the hospital or healthcare provider for an itemized bill that includes the billing codes of all the care you received. The Health Insurance Portability and Accountability Act (HIPAA) mandates that providers share this information.

Next, check whether the billing codes are accurate. Again, simply Googling the codes with the phrase “medical billing code” can help. If something is off, contesting your bill with your medical provider or physician’s office can yield changes.

Another approach: comparing the bill with insurance companies’ estimates of fair charges for services. If the price you were charged is more than average, you can have your costs lowered. You could even take the provider to small claims court over the discrepancy (or let them know you have a case).

Finally, compare your insurance company’s “explanation of benefits” to the bill. This explanation of costs covered and not covered must match the hospital’s bill. If they don’t, you have another reason not to pay, and to ask the provider to work with your insurance company further first.

Remember the process requires persistence

Despite the hassle, these steps can save you considerable sums of money. Even after taking these steps, you can always appeal health claims with your insurance company, if you think there is any reason the bills should be covered entirely or more than the company initially decided. You can also contact your state insurance commissioner for support.

“What we’ve seen in our research and the data is that those folks who appeal — and there are few who appeal — but for those who appeal, there’s a high level of overturning,” Pastaina said.