How to Dispute a Medical Bill That Exceeds Your Good-Faith Estimate
The No Surprises Act gives you the right to dispute a bill that is $400 or more over your good-faith estimate. Here is exactly how the Patient-Provider Dispute Resolution process works.
When you schedule a non-emergency medical service as an uninsured or self-pay patient, federal law requires the provider to give you a good-faith estimate of the expected cost in advance. If your final bill is $400 or more higher than that estimate, you have the right to dispute it through the Patient-Provider Dispute Resolution (PPDR) process. This right is created by the No Surprises Act and is separate from the surprise billing protections that apply to insured patients.
Who this applies to
The good-faith estimate requirement and the PPDR dispute process apply to uninsured patients and patients who choose to pay out of pocket rather than using their insurance. If you are using insurance, the good-faith estimate rules are different and the PPDR process as described here does not apply to your situation.
What a good-faith estimate must include
Providers are required to give you a good-faith estimate in writing at least one business day before your scheduled service. The estimate must list the expected charges for the primary service and any reasonably expected additional items or services associated with the visit, including charges from other providers at the same facility. If you receive care from multiple providers (for example, a facility fee and a separate physician fee), each provider should give you a separate estimate.
The $400 threshold
If your final bill is $400 or more higher than the good-faith estimate for the same item or service, you may initiate the dispute resolution process. The $400 threshold applies per provider, not to the total bill. If one provider's charges exceeded their estimate by $400 but another provider's charges were close to their estimate, you would dispute only the first provider's charges.
How to initiate the dispute
You must initiate the PPDR process within 120 days of receiving the final bill. To start the process, submit a dispute to a certified dispute resolution entity (CDRE). The federal government maintains a list of certified entities. The CDRE filing fee is capped at $25 for patients. Submit your good-faith estimate and your final itemized bill when you file.
The CDRE reviews the dispute and determines whether the final charge was appropriate or whether it should be adjusted to align more closely with the estimate. The CDRE decision is binding on the provider.
What makes a strong dispute
The strongest disputes are ones where the difference between the estimate and the final bill is clearly documented, the same service or item appears on both documents, and there is no clear explanation for the difference (no documented change in scope, no additional services requested). If additional services were added at your request during the visit, those additions may justify higher charges than estimated. The CDRE will consider this.
Limitations of the PPDR process
The PPDR process applies only to uninsured and self-pay patients, only when a good-faith estimate was required and provided, and only when the bill exceeds the estimate by $400 or more. It does not apply to surprise bills for insured patients (those are handled through different NSA protections), and it does not apply when no estimate was required (for example, emergency care).
If a provider failed to give you a required good-faith estimate, you can report that failure to the Centers for Medicare and Medicaid Services (CMS). Providers can face civil monetary penalties for failing to provide required estimates.
Ready to take action?
No Surprises Act Disputer can help you organize NSA-related disputes and notices. Medical Bill Analyzer can help you review itemized charges on the underlying bill.
Bill Advantage is a document literacy tool. Nothing in this article constitutes legal or medical advice.
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