Georgia — Challenging an Insurance Adjuster’s Reduction of Emergency Room Charges

Detailed Answer

Short answer: Yes — in Georgia you can challenge an insurance adjuster’s decision to reduce emergency-room (ER) charges. You can pursue internal appeals, gather documentation to dispute the insurer’s basis for reduction, file a complaint with the Georgia Office of Commissioner of Insurance, and, if necessary, bring a lawsuit (including contract claims and, in some cases, bad-faith claims under Georgia law). Federal protections like the No Surprises Act may also prevent balance billing for emergency services.

Why insurers reduce ER charges

• Insurers often pay an allowed amount rather than the hospital’s full billed charge. Billed charges (chargemaster rates) are usually much higher than what insurers consider reasonable.
• The adjuster may apply a network discount, usual, customary and reasonable (UCR) benchmark, a Medicare-based fee schedule, or a negotiated rate with the provider.
• Insurers sometimes dispute whether a service was medically necessary or whether the charge relates to the covered injury.
• For out-of-network emergency care, balance billing rules and federal law (No Surprises Act) affect how much a patient owes and how insurer/provider disputes get resolved.

What Georgia and federal law say

Georgia law allows remedies when an insurer acts in bad faith; one common statutory reference for insurer bad-faith claims is O.C.G.A. § 33-4-6. You can read the statute here: O.C.G.A. § 33-4-6. In addition, the federal No Surprises Act protects patients from surprise billing for most emergency services and establishes a dispute-resolution process between insurers and providers. Basic No Surprises Act information is available from CMS: CMS — No Surprises Act.

Practical steps to challenge a reduction of ER charges in Georgia

1. Get documentation. Ask the insurer for the Explanation of Benefits (EOB) and any written reason for the payment reduction. Ask the hospital for an itemized bill and for any contract terms if they are in a network.
2. Confirm emergency status and protections. If you truly received emergency services, the No Surprises Act usually limits balance billing and creates additional protections. Provide documentation showing the visit was for an emergency medical condition.
3. Ask for the specific basis for the reduction. Request the adjuster cite the policy provision, fee schedule, or benchmark used (for example, Medicare rates, a UCR database, or a PPO contract).
4. Collect medical records. Send the insurer the ER medical records and physician notes that show the visit was necessary and related to the injury.
5. Negotiate with the provider. Many hospitals will accept a reduced balance or write off part of the charge if the insurer pays only an allowed amount. Ask the provider for any network discounts or charity/financial assistance.
6. File an internal appeal. Use the insurer’s internal appeal process. Put your dispute in writing, attach supporting medical records and an itemized bill, and request reconsideration.
7. File a complaint with Georgia’s insurance regulator. If the insurer will not adequately explain or reverse the reduction, file a consumer complaint with the Georgia Office of Commissioner of Insurance: Filing a consumer complaint (Georgia OCI).
8. Consider demand letters or litigation. If the insurer refuses to pay amounts you believe are due under the policy or pays unreasonably low amounts, you can consider a demand letter from an attorney and, if needed, a civil suit for breach of contract or bad faith under Georgia law.

When federal law (No Surprises Act) may help

The No Surprises Act protects patients receiving emergency care from being balance-billed by out-of-network providers in many situations. If your ER visit meets the Act’s emergency standard, your insurer may be required to treat the service as in-network for patient cost-sharing purposes and resolve disputes about payment directly with the provider. See CMS for details: https://www.cms.gov/nosurprises.

When to consider an attorney in Georgia

Talk to an attorney experienced in Georgia insurance or personal injury law if:

• The insurer refuses to provide a written explanation for the reduction.
• The insurer’s payments leave you with an unexpected large balance and the provider won’t negotiate.
• You believe the insurer acted unfairly or in bad faith. A bad-faith claim under O.C.G.A. § 33-4-6 may be available in some cases: O.C.G.A. § 33-4-6.

Note: a civil lawsuit might recover only the reasonable value of medical services in tort cases rather than the provider’s full billed charges. Courts examine what was reasonable and necessary for treatment of your injury when awarding medical damages.

Helpful Hints

• Always get the insurer’s decision in writing. A documented reason helps you appeal or file a complaint.
• Ask the hospital for an itemized bill and for any contractual rate or discount they applied.
• Compare the insurer’s payment to Medicare rates or independent fee databases (e.g., FAIR Health) to see whether the insurer’s number is in line with common benchmarks.
• Keep organized records: ER records, bills, EOBs, phone notes (date/time/person spoken to), and written communications.
• If you receive a large surprise bill after emergency care, check federal No Surprises Act protections and contact the provider and insurer to trigger dispute-resolution if applicable.
• File a complaint with Georgia’s insurance regulator if the insurer won’t resolve the dispute: Georgia OCI consumer complaint.
• If you decide to hire an attorney, choose one familiar with Georgia insurance dispute practice and ER/billing issues.

Disclaimer: This article is for general information only and does not constitute legal advice. It does not create an attorney-client relationship. For advice tailored to your situation, consult a licensed attorney in Georgia.