Medical Debt After Cancer Treatment

This page is educational. It is not legal, tax, or financial advice. Rules vary by state, plan, and hospital.

Cancer bills arrive from many places at once. The hospital. The surgeon. The anesthesiologist. The pathology lab. The imaging center. The specialty pharmacy. Each has its own billing system, and none of them talks to the others.

That is why the first number you see is often wrong, or at least not final. Federal law gives you several tools here. Most people never use them, because nobody hands you the list. Here it is.

Ask for an itemized bill. Then match it to your Explanation of Benefits, or EOB, which is the insurer's summary of what it paid.

The National Cancer Institute (NCI) gives the instruction plainly: "match each bill you receive to the EOB statement from your insurance company. Ask about any differences you see between the EOB and the bill." NCI adds a line worth quoting to yourself: "it's your right to question your bill with the doctor or the insurance company."

NCI also suggests asking the billing office directly about "payment plans, reduced rates, patient assistance, help from charities."

The Centers for Medicare and Medicaid Services (CMS) states that this law took effect January 1, 2022. It protects you from surprise out-of-network bills for emergency room visits, for non-emergency care received at an in-network facility, and for air ambulance services.

The classic cancer example is a biopsy at an in-network hospital read by an out-of-network pathologist. You did not choose that pathologist. The law says you should not eat the difference.

If you are uninsured or paying cash, there is a second protection. CMS states that "providers must give you a good faith estimate of how much your health care will cost if you request one or schedule services at least 3 business days in advance." And here is the number to remember: you "may be able to dispute your bill if it's at least $400 more than the estimate."

CMS lists a help line for complaints: 1-800-985-3059, open seven days a week, with support in more than 350 languages.

Most US hospitals are tax-exempt charities. To keep that status, Internal Revenue Code section 501(r) forces them to do specific things. The rules are in the Code of Federal Regulations, and they are more generous than most billing offices volunteer.

Under 26 CFR 1.501(r)-4, every such hospital must have a written financial assistance policy, or FAP. The regulation requires it to state "the eligibility criteria for financial assistance and whether such assistance includes free or discounted care," "the basis for calculating amounts charged to patients," "the method for applying for financial assistance," and "the actions that may be taken in the event of nonpayment."

Two details in that rule are easy to miss and useful. The FAP must list "any providers, other than the hospital facility itself, delivering emergency or other medically necessary care," and say which of them the policy covers. So you can ask whether the surgeon's separate bill is inside or outside the policy. The hospital must also translate the FAP for any language group that makes up the lesser of 1,000 people or 5 percent of the community it serves, so the trigger can be well under 5 percent in a large city.

Under 26 CFR 1.501(r)-5, once you qualify, there is a ceiling on your bill. The hospital may charge you no more than "the amounts generally billed to individuals who have insurance covering such care," known as AGB. For everything else covered by the policy, it must charge "less than the gross charges."

AGB is not a mystery number. The regulation gives two ways to set it. The look-back method divides a year of insurer-allowed claim amounts by the matching gross charges. The prospective method charges what Medicare or Medicaid would have allowed. Ask which method your hospital uses and what its current AGB percentage is. If you already paid more than AGB and are later found eligible, the hospital must refund the difference when it exceeds $5.

Under 26 CFR 1.501(r)-6, a nonprofit hospital must wait before it can do the harsh things. The regulation calls those extraordinary collection actions, or ECAs. They include selling your debt, reporting you to credit agencies, placing liens, garnishing wages, attaching bank accounts, filing civil suits, and deferring or denying medically necessary care because of an old unpaid bill.

• 120 days. The hospital must "refrain from initiating such ECAs... for at least 120 days from the date the hospital facility provides the first post-discharge billing statement."
• 30 days. Before starting an ECA, it must give you written notice at least 30 days ahead, naming which actions it intends to take.
• 240 days. If the action is deferring or denying care over a past unpaid bill, your deadline to apply for financial assistance runs to the later of 30 days after that written notice, or 240 days after the first billing statement for the earlier care.

Read that as eight months of protected time on most bills. Apply inside it.

Once a bill leaves the hospital, a different law applies. The Federal Trade Commission (FTC) explains that a debt collector must give you validation information at first contact or within five days. That includes its name and address, the name of the creditor, the amount owed, and how to dispute.

You then have 30 days to dispute in writing. FTC states that once you do, the collector "must stop trying to collect the debt until it sends you written verification of the debt, like a copy of the original bill." For a cancer bill assembled from six billing systems, that verification is often where errors surface.

FTC also sets limits on contact. Collectors may not call "before 8 a.m. or after 9 p.m." They may not call "more than seven times within a seven-day period."

Do not pay a large surprise bill before checking financial assistance and the No Surprises Act. Money paid is much harder to claw back than money not yet paid.

Do not treat an EOB as a bill. It is a statement, and it often arrives first.

Do not put treatment bills on a credit card to make them go away. Doing that converts a debt with legal protections and a possible charity write-off into ordinary consumer debt with neither.

Do not stay silent because the number is embarrassing. Silence is what starts the collection clock.

Ask the hospital for a financial counselor and for the FAP application, in writing. NCI notes that hospital social workers can "suggest organizations or other programs that could help you pay for cancer treatment." Also ask your oncology practice whether it has a financial navigator, and whether drug-maker assistance or copay foundations cover any of your specific drugs.

See also Financial Assistance for Cancer, Insurance Denials and Appeals, and Understanding Your Health Insurance.

• https://www.cancer.gov/about-cancer/managing-care/track-care-costs
• https://www.cms.gov/medical-bill-rights
• https://www.ecfr.gov/current/title-26/chapter-I/subchapter-A/part-1/section-1.501(r)-4
• https://www.ecfr.gov/current/title-26/chapter-I/subchapter-A/part-1/section-1.501(r)-5
• https://www.ecfr.gov/current/title-26/chapter-I/subchapter-A/part-1/section-1.501(r)-6
• https://consumer.ftc.gov/articles/debt-collection-faqs