Can I challenge the adjuster’s decision to reduce my ER charges in my injury claim?

Short answer: Yes — in most cases you can challenge an insurer’s reduction of emergency room (ER) charges. You should gather the bill and explanation of benefits (EOB), ask for a written explanation for the reduction, compare the payment to the provider’s billed charges or contracted rates, and escalate the dispute to the insurer, the health care provider, and the Indiana Department of Insurance if needed. If the dispute is large or the insurer refuses to negotiate, consult a personal injury attorney.

Detailed answer — step‑by‑step under Indiana law and practice

This section explains why an insurer might reduce ER charges, what rights you and your health care provider may have, and the practical steps to challenge the reduction in Indiana. This is general information and not legal advice.

Why insurers reduce ER charges

• Network or contract discounts: If the provider is in the insurer’s network, the insurer may pay the agreed contractual rate — which is lower than the provider’s full charge.
• Usual, customary, and reasonable (UCR) or “reasonable value” determinations: For out‑of‑network charges, insurers frequently pay only what they consider the reasonable amount for the locality (UCR), leaving the remainder as the patient’s responsibility.
• Billing or coding errors: The insurer may deny part of a bill for incorrect codes, missing information, or claims processing errors.
• Medical necessity or emergency determination: Insurers sometimes deny or reduce payment if they contend some services were not medically necessary or should have been handled differently.
• Coordination of benefits / subrogation / lien issues: Other insurers, Medicare/Medicaid rules, or provider liens can affect what is paid.

Who can challenge the reduction?

Three parties commonly challenge reductions:

• You, the injured person, if you were billed for a balance you believe is improper.
• The medical provider (hospital, ER physician, or billing company) if the provider seeks full payment from you or places a lien against a third‑party recovery.
• Your health insurer (if separate) or your attorney, who can negotiate directly with the insurer handling the liability claim.

Practical steps to challenge the reduction

1. Get the documents. Request and keep: the itemized hospital bill, the insurer’s Explanation of Benefits (EOB), any notice of claim adjustment, and the provider’s medical records for the ER visit.
2. Ask for a written explanation of the reduction. Contact the claims adjuster and request a precise, written reason for the reduction and a copy of any internal guidelines or UCR schedule used to make the decision.
3. Check whether a network or assignment applies. If the ER provider is in the insurer’s network, the insurer generally pays the contracted rate. If the provider accepted assignment of benefits from you, the provider may have a direct right to pursue the insurer for payment.
4. Confirm whether the bill was coded correctly. Small coding errors or missing modifiers can cause denials. Ask the provider’s billing office to review and, if appropriate, re‑submit the claim with corrected codes and supporting records.
5. Negotiate or demand reconsideration. Send a written demand to the insurer asking for reconsideration and attaching the itemized bill, clinical records showing an emergency, and any other supporting documentation. Ask the provider to submit an appeal on its own billing letterhead if the provider will assist.
6. Escalate to the Indiana Department of Insurance (IDOI). If the insurer refuses to explain or reconsider, you can file a consumer complaint with IDOI. The IDOI mediates consumer complaints about insurer conduct. See: Indiana Department of Insurance — File a Complaint.
7. Consider a demand letter or lawsuit against the at‑fault party’s insurer. If the ER charges are part of a third‑party liability claim (another driver caused your injury), your attorney can present a settlement demand that includes full billed charges or negotiated provider liens and negotiate or file suit for the full value of your damages.
8. Get legal help when necessary. For large bills, persistent denials, or complex lien/subrogation issues, consult a personal injury lawyer who understands how to preserve medical liens, negotiate provider reductions, and, if needed, file suit before applicable deadlines.

Special issues in Indiana to watch for

• Provider liens and right of reimbursement: Many Indiana hospitals and providers will place a lien on a personal injury recovery or require a written assignment of benefits. If a provider has a lien or assignment, the provider can pursue payment from the insurer or your settlement proceeds.
• Medicare, Medicaid, and subrogation: If public payers provided or coordinated payment, federal and state reimbursement/subrogation rules can change who gets paid and how much.
• Timeliness: Do not wait. Administrative appeals and civil claims have deadlines. Preserve your records, respond to collection attempts, and consult an attorney if you receive a lawsuit or a provider lien.

When to hire a lawyer

Hire an attorney if any of the following apply:

• The insurer will not provide a reasonable explanation or refuses to negotiate despite clear supporting medical records.
• The ER bill is large and the provider is threatening collections or has placed a lien.
• There are multiple insurers, Medicare/Medicaid, or a likely subrogation claim complicating recovery.
• You need someone to present a demand for full value or file suit to recover damages from the at‑fault party’s insurer.

Sample short demand language you can send to an insurer

“Please reconsider claim adjustment for [patient name] ER visit on [date]. Enclosed: itemized bill and records showing emergency treatment. The services billed were emergency and reasonable given the clinical presentation. We request a full written explanation of any reduction with calculations and the evidence relied upon.”

Helpful Hints

• Keep all paperwork: bills, EOBs, medical records, claim numbers, adjuster names, and dates of calls.
• Ask for all communications in writing; oral explanations are less useful later in disputes.
• Request that the provider re‑submit claims if you suspect coding errors.
• If the provider is in‑network, confirm the insurer applied the contracted rate correctly.
• If a provider places a lien or intends to pursue your settlement, get the lien in writing and ask the provider to explain how it calculated its amount.
• Use the Indiana Department of Insurance for consumer complaints: https://www.in.gov/idoi/consumers/file-a-complaint/.
• Act quickly — preserve evidence and be mindful of any deadlines for appeals, administrative complaints, or civil suits.

Disclaimer: This article is for general informational purposes only and does not constitute legal advice. It does not create an attorney‑client relationship. Laws change and every case is different. Consult a licensed Indiana attorney to get advice tailored to your situation.