How to Challenge Facility Fees on Medical Bills with a Two‑Step Call Script

Facility fees often appear as a separate “hospital” charge for care at hospital‑owned clinics, outpatient departments, or even telehealth. You’re not bad at money—you’re under‑practiced at conversations. Here’s a short, two‑step call script that favors brevity, empathy, and escalation paths. We’ll first ask the provider to itemize and justify the fee (and remove it if policy or law supports that). Then we’ll ask your health plan to re‑review coding and apply plan rules—especially the correct place‑of‑service (POS) code and how the plan treats facility fees under federal transparency rules. Laws vary by state; I’ll note where to check and what to ask for.

Use the script; confirm in writing; tag the result so it sticks.

Call Map (one screen)

Open → polite context and account details
Ask → itemized bill, codes, claim type, “is this a facility fee?”
Pause → let them look; wait in silence
Counter → cite policy/law; ask for waiver or reprocessing
Confirm email → “Please email the itemized bill/policy”
Goodbye → recap next steps and reference number

Step 1: Provider Billing Office (Goal: itemize, justify, remove/waive) Mini play

Caller: Hi there—calling about account [number] for [date] at [clinic/facility]. I see a separate line labeled “facility” or “hospital outpatient.” I’d like a fully itemized bill and to review that fee.

Agent: I can help. What would you like to see?

Caller: Please email an itemized statement with CPT/HCPCS codes, revenue codes, the place‑of‑service code, and whether this was billed on a CMS‑1500 or UB‑04. Also, can you confirm: is this charge a facility fee?

Agent: Yes, it’s a facility fee.

Caller: Thanks. Was this billed as hospital outpatient (HOPD)? If so, is this clinic a provider‑based department that meets 42 CFR §413.65? If not, please adjust the billing.

Agent: We always charge facility fees.

Caller: Under state rules and hospital transparency requirements, I need the written basis for this fee. Please point me to your public price estimator or machine‑readable file for this service and setting. If the posted data doesn’t support this fee or the required notice wasn’t provided, please remove or waive it.

If pushback → use line B Caller: My state has facility‑fee limits/notice rules for routine or telehealth visits. If notice was missing or the service is restricted under state law, please remove the fee and send the corrected statement today. Otherwise, please email your written policy and the specific statute you’re relying on.

If telehealth or routine primary care → use line C Caller: For [telehealth/primary/preventive] care, several states restrict or ban facility fees, and bills must clearly disclose them. Since I didn’t receive advance notice, I’m asking that you waive the fee and issue a corrected bill.

If they defend the fee → anticipate with line D Caller: I understand hospitals say facility fees cover standby resources. For my visit, please identify which facility resources applied. If they were not used or notice wasn’t given, please remove the fee.

If it seems mis‑coded → use line E Caller: This looked like an office visit, not a hospital‑outpatient encounter. Please confirm the POS. If it should be POS 11 (office) rather than POS 22 (outpatient hospital), please correct and resend the claim.

Ask for relief even if they say no Caller: If the fee can’t be removed, please review charity‑care or discount options and any prompt‑pay or policy‑based reductions. Please email a decision today.

Close the call Caller: Great—please send the itemized bill, your policy, and a ticket/reference number to [email]. I’ll follow up by [date]. Thank you.

Why these asks work

Itemized bill with codes: You’re verifying CPT/HCPCS, revenue codes, and POS and clarifying whether it was billed on the professional claim (CMS‑1500) or the institutional claim (UB‑04).
Provider‑based billing check: 42 CFR §413.65 frames when a department may bill as hospital‑based.
Price transparency leverage: Hospitals must publicly post standard charges and shoppable prices; enforcement intensified in 2024–2025. If data is missing or noncompliant, that’s negotiation leverage and grounds for a complaint.
Telehealth and routine services: States such as Connecticut, Colorado, Washington, and Ohio restrict or ban certain facility fees and require notices or itemization. Where notice was missing or the service falls under a state restriction, ask for removal.

Step 2: Your Health Plan (Goal: re‑review coding, apply plan rules, appeal if needed) Mini play

Caller: Hi—calling about claim [number], provider [name], date of service [date]. I’m requesting a re‑review for correct place‑of‑service and any facility fee.

Agent: What’s the concern?

Caller: The provider billed as outpatient hospital (POS 22), but this appeared to be an office‑setting visit (POS 11). Please reprocess if POS 11 applies. Also, confirm the claim form(s) received—CMS‑1500 and/or UB‑04—and how the plan treats any facility fee.

Agent: Our tool shows the cost estimate.

Caller: Under federal transparency guidance, plan tools and good‑faith estimates must account for covered facility fees. Please confirm whether your tool and any advanced EOB include facility fees for this service and setting, and share the estimate.

If pushback → use line B Caller: If the provider asserts HOPD status, please request documentation. If POS or site is unclear, send the claim for re‑review and issue a written reconsideration decision.

If you’re self‑pay or uninsured → use line C Caller: I have a Good Faith Estimate of [amount]. The bill is at least $400 higher. Please confirm steps for the Patient‑Provider Dispute Resolution process; I intend to file within 120 days.

If still unresolved → use line D Caller: Please open a reconsideration/appeal and send the instructions by email. Also share your complaint channels and, if appropriate, how to file a No Surprises complaint. I’ll need a reference number for this call.

Close the call Caller: Thanks. Please email the re‑review outcome, the POS determination, and any appeal or complaint info to [email]. I appreciate your help.

What to document

The itemized statement and codes (CPT/HCPCS, revenue, POS).
Whether the clinic is treated as a provider‑based HOPD.
Links or PDFs from the hospital’s price estimator or machine‑readable file reflecting the fee.
Health plan’s POS determination (POS 11 vs POS 22) and any reconsideration outcome.
If self‑pay: your GFE, the billed amount, and whether the $400 PPDR threshold applies; PPDR must be filed within 120 days.
Call reference numbers and email confirmations.

After the call (keep it simple)

Send a short recap email: “Per our call today, please confirm [fee waived]/[claim reprocessed]/[appeal opened] by [date].”
If you use Monee: tag the renegotiated bill and, if the fee is waived or reduced, adjust your medical or “Clinics/Hospitals” category cap so future months reflect the change.

Printable Script (fill‑in blanks) Use this page during calls and attach your itemized bill and EOB.

Patient: __________________________ Account/Claim #: ______________________ Provider/Facility: ________________________________________________________ Date of Service: __________________ Visit Type: [telehealth/in‑person] ______ Suspected Facility Fee Line(s): ___________________________________________ Your Email for Documents: _______________________________________________

Step 1 — Provider Billing Office

“I’m calling about account [number] for [date]. Please email an itemized bill with CPT/HCPCS, revenue codes, the POS code, and whether this was billed on CMS‑1500 or UB‑04.”
“Is this a facility fee tied to provider‑based billing? If so, please confirm the department’s status and the posted standard charge.”
“Because [no notice/telehealth/preventive/routine clinic], I’m asking you to remove or waive the facility fee and send a corrected bill.”
“If not removed, please review charity‑care or discount options.”
“Please email your decision and a reference number by [date].”

Step 2 — Health Plan

“For claim [number], please re‑review POS coding. I believe POS 11 applies; if so, reprocess and adjust any facility fee.”
“Confirm whether your price tool and GFEs include facility fees for this service setting.”
“If denied, open a reconsideration/appeal and email the instructions and timelines.”
Self‑pay: “My GFE was [amount]; the bill is ≥$400 higher. I plan to file PPDR within 120 days. Please confirm steps.”
“Please email the outcome and call reference number by [date].”

Expert Summary From 2023–2025, federal agencies clarified that health plans’ price tools and good‑faith estimates must include facility fees, and hospital price‑transparency enforcement intensified—giving patients leverage to question and compare these charges. States accelerated limits and disclosures: several now restrict or ban facility fees for telehealth and certain routine or preventive services, require conspicuous pre‑service notice and itemized billing, and impose penalties for noncompliance. Practically, the strongest approach is a two‑step challenge: ask the provider to itemize and justify any facility fee—seeking removal if notice was missing or a state restriction applies—then ask the insurer to reprocess the claim for the correct place‑of‑service code (POS 11 vs POS 22) and apply plan rules for covered facility fees. If you are self‑pay and your bill exceeds the GFE by $400 or more, file a Patient‑Provider Dispute Resolution within 120 days; otherwise submit a No Surprises complaint and mention hospital transparency gaps if relevant. Along the way, check hospital machine‑readable files and estimators, compare against your EOB, and cite state statutes and federal FAQs to speed adjustments or financial‑assistance reviews.

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How to Challenge Facility Fees on Medical Bills with a Two‑Step Call Script

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