💲 Medical Billing Dispute Calculator
Enter your bill details below to calculate potential overcharges and estimate a fair payment amount. This calculator helps you understand how much you may be able to dispute or negotiate.
Total amount billed by the provider
Amount your insurance paid (from EOB)
What they say you owe (balance after insurance)
Optional - Medicare pays this for the same service
Helps estimate typical markup rates
Affects what rates apply to you
Your Billing Analysis
Original Bill
$0
Insurance Paid
$0
They Claim You Owe
$0
Reasonable Rate (Est.)
$0
Potential Overcharge
$0
Fair Patient Portion
$0
Detailed Breakdown
Original Billed Amount
$0
Estimated Medicare Rate
$0
Reasonable/Customary Rate (150-200% Medicare)
$0
Insurance Payment
$0
Markup Over Reasonable Rate
0%
Amount Above Reasonable Rate
$0
Suggested Dispute Amount
$0
Next Steps
Based on your calculation, here are recommended actions...
Calculator Disclaimer
This calculator provides estimates based on typical industry markups. Actual reasonable rates vary by procedure, location, and facility type. For precise Medicare rates, visit CMS.gov or use FAIR Health Consumer tools. This is for educational purposes only and is not legal advice.
📚 Understanding Your Medical Bill
Key Terms Explained
Chargemaster Rate (Original Bill)
This is the hospital's list price - often inflated 300-1000% above actual costs. Almost nobody pays chargemaster rates. Insurance companies negotiate these down significantly.
Allowed Amount
The amount your insurance considers reasonable for a service. In-network providers agree to accept this as full payment. Out-of-network providers may bill you for the difference (balance billing).
Medicare Rate
What Medicare pays for the same service. This is a good benchmark for reasonable costs. Most experts consider 150-200% of Medicare to be a fair commercial rate.
Reasonable and Customary (UCR)
The typical charge for a service in your geographic area. If a provider charges significantly more than UCR, you may have grounds to dispute the excess as unreasonable.
⚖ California Laws Protecting Patients
California has strong patient protections against excessive medical billing:
Health & Safety Code 127400-127446 - Hospital Fair Pricing
Hospitals cannot charge uninsured patients more than the highest amount paid by government payers. Patients below 400% of federal poverty level qualify for charity care or discounted rates.
AB 774 - Hospital Bill Protections
Requires hospitals to have charity care policies, offer reasonable payment plans, and provide financial assistance to qualifying patients. Hospitals must post pricing information.
Civil Code 1798.102 - Medical Debt Protections
Limits when medical debt can be sent to collections and requires notification before reporting to credit bureaus. Provides rights to dispute and negotiate before credit damage.
📈 Typical Hospital Markup Rates
Understanding how much hospitals typically mark up services helps you identify potential overcharges:
| Service Type | Typical Markup (Over Cost) | Reasonable Rate (% of Medicare) |
|---|---|---|
| Emergency Room Visit | 300-600% | 150-200% |
| Surgery/Procedures | 400-800% | 150-250% |
| Imaging (MRI, CT) | 500-1000% | 150-200% |
| Laboratory Tests | 300-800% | 125-175% |
| Inpatient Stay (per day) | 400-700% | 175-250% |
| Prescription Drugs | 200-600% | 125-200% |
Find Medicare Rates for Your Procedure
Look up exact Medicare rates at cms.gov/medicare/payment or use fairhealthconsumer.org to see typical charges in your area. Request CPT codes from your provider to search accurately.
❓ Frequently Asked Questions
What is a reasonable and customary rate for medical services?
A "reasonable and customary" rate (also called "usual and customary" or UCR) is the amount typically charged for a medical service in a specific geographic area. Insurance companies use this benchmark to determine fair payment. Charges significantly above the Medicare rate (often 200-300% of Medicare is considered reasonable for most services) may be considered excessive and can be disputed.
How do I know if I'm being overcharged for medical services?
Compare your bill to Medicare rates for the same procedure (available at cms.gov). Hospital charges that exceed 300-400% of Medicare rates are often considered excessive. You can also use FAIR Health Consumer tools to compare prices in your area. If your charges significantly exceed these benchmarks, you may have grounds for a billing dispute.
What is the difference between what I'm billed and what I should pay?
Your original bill (billed charges) is often inflated "chargemaster" rates. After insurance negotiates, they pay an "allowed amount." Your patient responsibility includes copays, coinsurance, and deductibles. If you're uninsured or out-of-network, you may be billed full chargemaster rates - but you can negotiate down to reasonable rates, often 150-200% of Medicare.
Can I dispute medical bills I think are too high in California?
Yes. California law provides several protections: AB 774 requires hospitals to offer charity care and payment plans, Health & Safety Code 127400-127446 limits what hospitals can charge uninsured patients, and you can always negotiate bills or dispute charges you believe are incorrect or excessive. Request an itemized bill and compare each charge to fair market rates.
Should I pay my medical bill while disputing it?
You can make partial payments on undisputed amounts while disputing the rest. Send a letter stating your payment is for the undisputed portion only and you are actively disputing the remainder. Keep records of all payments and correspondence. California law protects you from collections on actively disputed amounts.
Large Medical Bill Dispute? I Can Help.
For bills over $10,000 or complex disputes with hospitals and insurers, I can assist with demand letters, regulatory complaints, and negotiation.
Contact: owner@terms.law📅 Schedule a Consultation
For complex medical billing disputes or claims involving multiple providers, book a call to discuss your options.
📝 Create Your Demand Letter
Generate a professional demand letter, CA court complaint, or arbitration demand