Review Medical Bill

Analyze a medical bill or Explanation of Benefits (EOB) against the user's insurance benefits summary to determine if charges are correct and identify any disputable items.

Workflow

Step 1: Gather the bill

Ask the user:

Please provide the bill or EOB to review. You can share a screenshot, paste a file path, or drop the PDF here.

Read the document. Extract:

• Provider name
• Date(s) of service
• Claim number (if EOB)
• Invoice number (if bill)
• Each line item: service description, CPT code (if shown), amount billed, adjustments, insurance paid, patient responsibility
• How patient responsibility breaks down: copay, deductible, coinsurance, not covered

Step 2: Load the benefits summary

Read the stored benefits summary from:

~/.claude/skills/dispute-medical-bill/references/Benefits.pdf

If the file doesn't exist or is outdated, ask the user to provide their current Summary of Benefits and Coverage (SBC) document, then save it to the references directory for future use.

Step 3: Ask clarifying questions

Ask the user these questions (only the ones relevant to the bill):

1. What type of visit was this? (annual physical/preventive, specialist visit for symptoms, urgent care, ER, surgery, etc.)
2. Was there a specific symptom or condition that prompted this visit? (This is critical -- the same test can be preventive or diagnostic depending on the reason.)
3. Have you already contacted the provider about this bill? (e.g., asked them to recode, and they refused or haven't responded yet?) If the user has already tried the provider route and been denied, skip to Step 7 for insurer escalation.

Do NOT ask questions that are already answered by the documents.

Step 4: Analyze each line item

For each charge, determine:

1. What benefit category does this fall under? Map the service to the correct row in the SBC (e.g., specialist visit, diagnostic test, preventive screening, emergency room, etc.)

2. Is the cost-sharing correct? Check:

   • Is the copay amount correct per the SBC?
   • Was the deductible correctly applied (or correctly waived for services exempt from deductible)?
   • Is the coinsurance percentage correct?
   • For preventive services: there should be NO cost-sharing and NO deductible for in-network providers

3. Key rules to check:

   • Preventive vs Diagnostic: If the visit was for an annual physical / routine screening with no symptoms, labs and screenings should be coded as preventive (ICD-10 codes starting with Z00) and covered at 100% in-network with no deductible. If there were symptoms or a specific condition, diagnostic coding is appropriate and deductible/coinsurance apply.
   • Specialist copay: Should match the SBC amount for specialist visits. Many plans waive the deductible for office visits — check the SBC.
   • Diagnostic tests: Subject to deductible, then coinsurance at the rate specified in the SBC.
   • Balance billing: In-network providers cannot balance bill beyond the allowed amount.

4. Classify each line item:

   • Legitimate -- charge is correct per the plan terms
   • Disputable -- charge appears incorrect or could be recoded
   • Needs investigation -- cannot determine without more info

Step 5: Present findings

Output a structured analysis:

Charge Breakdown Table

For each line item, explain:

• Why it's legitimate, disputable, or needs investigation
• Cite the specific SBC provision that applies
• If disputable, explain the argument and likelihood of success

Deductible tracker

Note how much of the annual deductible has been met (if shown on EOB) and how this charge affects it.

Step 6: Draft communication (if any items are disputable)

If there are disputable charges, ask:

Would you like me to draft a message to [provider/insurer]?

If yes, draft a concise message that includes:

• Specific invoice/claim numbers and dates of service
• Dollar amounts in question
• The specific ask (confirm coding, resubmit, appeal)
• Reasoning tied to the plan terms

Keep the tone professional and factual. Do not overstate the case or claim something is preventive when symptoms were involved.

Step 7: Insurer escalation (if provider won't recode)

If the user has already contacted the provider and been denied or ignored, tell them to contact their insurance company directly. Provide:

1. Who to contact: The insurer's customer service number (found on the EOB or back of ID card)
2. What to say: Draft a message or talking points the user can use when calling, emailing, or messaging their insurer. Include:
   • Claim number and date of service
   • The specific charge being disputed and dollar amount
   • What they asked the provider to do and the provider's response
   • Why the charge should be covered differently, citing specific SBC provisions
   • The ask: request the insurer to reprocess the claim, or initiate a formal appeal
3. Reasoning: Explain clearly why the user believes the charge is incorrect, grounded in the plan's benefit terms. This helps the user advocate for themselves confidently.

Important Guidelines

• Never tell the user to claim something is preventive if symptoms or a diagnosis prompted the visit. This is the most common mistake and will backfire.
• Be honest about what's disputable vs legitimate. The user trusts this analysis to decide whether to pay or fight.
• Include specific document references -- claim numbers, invoice numbers, dates, dollar amounts. Vague disputes get ignored by billing departments.
• Check for the provider billing separately from the facility. A single visit can generate multiple bills (physician fee + facility fee + lab fee).
• Note appeal deadlines if shown on the EOB (typically 180 days from receipt).
• If the benefits PDF is for a different plan year than the date of service, warn the user.