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No Mercy

Don’t Ask for Mercy. Demand Fairness.

February 21, 2025

An estimated 55 million Americans receive a problem medical bill annually, so it is not surprising that there is no shortage of advice for patients receiving problem medical bills.  A January article in Time, “How to Negotiate Your Medical Bills”, is a good example of typical advice.  Its suggestions include asking the provider about financial assistance and payment plans or discounts, and advises that “the way you’re not going to win [against a problem medical bill] is having someone who’s screaming, because you’re trying to convince another person to help you.”  Although I also don’t suggest screaming at a provider, the article is an excellent example of how conventional wisdom is misguided regarding addressing a medical bill that one thinks is unfair, illegal, or that he or she may not owe.  When a patient confronts such a medical bill, the patient should not be “trying to convince [the provider] to help,” but disputing to the provider that he or she owes the bill.


Common suggestions to address a problem medical bill may sound reasonable, but they are based on a fundamentally flawed assumption: that the patient owes the medical bill as-is unless the provider agrees to lower it.  That may be true if the patient and provider had clearly agreed to the payment terms reflected in the medical bill, and there are no legal or other reasons for the bill to be invalid.  But with most problem medical bills, the bill is not consistent with a prior understanding between the patient and provider, or the patient has a concern about the fairness or legality of the bill.  In these common situations the patient should not assume that the provider must agree to lower the bill, and that otherwise the patient owes the medical bill as-is.  In other words, do not assume that it is the provider’s sole discretion whether to adjust a medical bill if the patient has legitimate concerns about the bill.  Under such an assumption, the patient is putting all the power in the hands of the provider, and is asking the provider for a favor to get any relief.  Giving all the decision making to the other party, and then asking that party for leniency, is usually not a good way to stick up for one’s interests in a dispute.

Medical services are provided via a market transaction involving a buyer (the patient) and seller (e.g. hospital, physician, etc.). Although the medical services marketplace has many unique features (e.g. potentially highly inelastic demand, third party insurance reimbursement) there is no reason to give special deference to medical providers as sellers that is rationally not afforded sellers in other markets. Whether it is buying a car or a trip the grocery store, consumers do not defer to the car dealer or supermarket as superior to the customer so that the seller can bill for goods and services at its discretion, and cannot be questioned or challenged by the customer. If the bill of sale for a new car doesn’t reflect the agreed-upon price or options, the car buyer will demand that the price be corrected to complete the sale. If a grocery store rings up a loaf of bread at a price of $50, the customer will expect the clerk to correct the overcharge or justify why the bread is so expensive. Patients should expect to exercise the same control and independence in ensuring fair treatment in paying for medical services as they do in these other transactions.

Common suggestions to address a problem medical bill may sound reasonable, but they are based on a fundamentally flawed assumption: that the patient owes the medical bill as-is unless the provider agrees to lower it. That may be true if the patient and provider had clearly agreed to the payment terms reflected in the medical bill, and there are no legal or other reasons for the bill to be invalid. But with most problem medical bills, the bill is not consistent with a prior understanding between the patient and provider, or the patient has a concern about the fairness or legality of the bill. In these common situations the patient should not assume that the provider must agree to lower the bill, and that otherwise the patient owes the medical bill as-is. In other words, do not assume that it is the provider’s sole discretion whether to adjust a medical bill if the patient has legitimate concerns about the bill. Under such an assumption, the patient is putting all the power in the hands of the provider, and is asking the provider for a favor to get any relief. Giving all the decision making to the other party, and then asking that party for leniency, is usually not a good way to stick up for one’s interests in a dispute.

Medical services are provided via a market transaction involving a buyer (the patient) and seller (e.g. hospital, physician, etc.).  Although the medical services marketplace has many unique features (e.g. potentially highly inelastic demand, third party insurance reimbursement) there is no reason to give special deference to medical providers as sellers that is rationally not afforded sellers in other markets.  Whether it is buying a car or a trip the grocery store, consumers do not defer to the car dealer or supermarket as superior to the customer so that the seller can bill for goods and services at its discretion, and cannot be questioned or challenged by the customer.  If the bill of sale for a new car doesn’t reflect the agreed-upon price or options, the car buyer will demand that the price be corrected to complete the sale.  If a grocery store rings up a loaf of bread at a price of $50, the customer will expect the clerk to correct the overcharge or justify why the bread is so expensive.  Patients should expect to exercise the same control and independence in ensuring fair treatment in paying for medical services as they do in these other transactions.

A patient who thinks that a medical bill is unfair, inaccurate, or unlawful needs to dispute the bill with the provider. Through a formal letter of dispute, the patient can clearly present concerns and questions about the bill, and require that the provider reasonably address those issues before the patient can determine what, if anything, he or she owes under the bill. The dispute is not a plea for the provider to help the patient on the bill. The dispute is a demand for the provider to address reasonably the patient’s concerns and questions, and makes resolving the dispute a condition for any payment of the bill.

A letter of dispute is not a cure-all.  Many providers will try to ignore the letter, and continue to seek payment on the bill as if the patient hasn’t questioned it.  Fortunately, many new consumer protections against problem medical bills have been adopted in recent years, including the federal No Surprises Act, that prohibit some of the most pernicious billing practices.  That doesn’t mean all providers adhere to these laws.  Many patients will find that persistence in a medical bill dispute can be just as important as having legal protections and legitimate concerns about the bill.  By adhering to the letter of dispute, and requiring the provider to address reasonably the letter’s concerns and questions as a condition for any payment of the bill, the patient can press the provider to give attention to the dispute.  This requires stamina from a patient, but is far more likely to yield a positive outcome than simply asking the provider for help.  After all, if the provider disregards or tries to thwart a patient’s dispute of a problem medical bill, that provider was unlikely to offer much or any genuine help on the bill if the patient had simply asked nicely.

No, one doesn’t need to scream at a hospital billing associate to address a problem medical bill. However, patients should not confuse proper etiquette with deference to the provider on whether a bill is unfair, and should be reduced or withdrawn. Patients should remember:  Don’t: Don’t ask for mercy. Demand fairness. 

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