Hospital Bill Appeals in Maryland — Know Your Rights

Maryland operates a unique all-payer hospital rate-setting system through the Health Services Cost Review Commission (HSCRC) — the only state in the country where a state agency sets the rates that all payers (Medicare, Medicaid, and commercial insurers) pay for hospital services. This system theoretically prevents the price variation common elsewhere, but billing errors still occur. The HSCRC (hscrc.maryland.gov) has regulatory authority over hospital charges. Johns Hopkins Medicine, University of Maryland Medical System, and MedStar Health all operate under HSCRC oversight.

What Makes Maryland Hospital Billing Different From Other States?

Maryland operates under a unique hospital rate-setting system administered by the Health Services Cost Review Commission (HSCRC). The HSCRC sets the rates that hospitals can charge for services — meaning Maryland hospitals are subject to rate regulation in a way that most other states simply are not. This system applies to most acute care hospitals in Maryland and covers both insured and uninsured patients.

In practical terms, this means that Maryland hospitals are generally required to charge the same rate for a given service regardless of whether the patient has private insurance, is uninsured, or is on Medicaid. This is sometimes called the "all-payer" model. If a hospital bills you at a rate that differs from its HSCRC-approved rate schedule, that is a potential compliance violation — and a strong basis for a billing dispute.

You can look up approved hospital rates through the HSCRC public data portal at hscrc.maryland.gov. This information is publicly available and can be a powerful reference when auditing your bill.

Does Maryland Have Balance Billing Protections?

Yes. Maryland has enacted meaningful balance billing protections that go beyond the federal No Surprises Act. Under Maryland law, patients with insurance who receive care at an in-network facility generally cannot be billed by out-of-network providers for the difference between their charges and what your insurer paid — this is commonly referred to as a surprise balance bill.

Maryland's balance billing law covers situations such as:

• An out-of-network anesthesiologist, surgeon, or assistant surgeon at an in-network hospital
• An out-of-network radiologist or pathologist reading tests ordered during your stay
• Emergency care from any provider, regardless of network status

It is also worth noting that under the federal No Surprises Act, protections for emergency care are absolute — no consent form can waive your right to in-network cost-sharing for emergency services. For certain non-emergency services at out-of-network facilities, a notice-and-consent process may apply, but emergency protections cannot be signed away under any circumstances. If you believe you have received an improper balance bill, you can file a complaint directly with the Maryland Insurance Administration or at cms.gov/nosurprises.

How Do I Request an Itemized Bill and What Should I Look For?

Your first concrete step in any billing dispute is requesting a complete, line-by-line itemized bill. The right to an itemized bill comes from state laws and CMS Conditions of Participation — not from the No Surprises Act, which separately gives you the right to a Good Faith Estimate before scheduled services. These are two distinct rights.

Contact the hospital's billing department in writing (email or certified mail) and request an itemized statement listing every charge with its corresponding CPT code or revenue code. Hospitals are generally required to provide this upon request. Once you have it, review it line by line for:

• Duplicate charges — the same procedure, medication, or supply billed twice
• Upcoding — a procedure coded at a higher complexity level than what was actually performed
• Unbundling — services that should be billed together under one code being split into multiple charges
• Phantom charges — items billed that you have no record of receiving (a common example: patients commonly report being charged for a private room when they were in a shared room, or for supplies they never saw used)
• Incorrect patient information — wrong diagnosis codes, wrong admission dates, or wrong insurance information that caused a claim to be denied or mispriced
• Newborn charges billed to the mother — a frequent issue in maternity billing, where a baby's charges are billed under the mother's account

Billing auditors and patient advocates frequently cite error rates in complex hospital bills as high as 80%, though estimates vary. Do not assume your bill is correct simply because it arrived from a large institution.

What Are Average Hospital Birth Costs in Maryland?

Hospital birth costs in Maryland vary significantly depending on the facility, type of delivery, length of stay, and insurance coverage. As a general ballpark, patients commonly report that:

• A vaginal delivery at a Maryland hospital may carry a billed charge in the range of $10,000–$18,000 before insurance adjustments
• A cesarean section may be billed in the range of $18,000–$35,000 or more, depending on complications
• A stay in the Neonatal Intensive Care Unit (NICU) can add thousands of dollars per day

Because the HSCRC regulates hospital rates in Maryland, you can cross-reference charges against published rate data — something patients in most other states cannot do. What you are actually responsible for paying out of pocket will depend on your insurance plan's deductibles, co-insurance, and out-of-pocket maximum. Always compare your itemized bill against your Explanation of Benefits (EOB) from your insurer before paying anything.

How to Dispute a Hospital Bill in Maryland — Step by Step

1. Request your itemized bill in writing from the hospital billing department.
2. Request your medical records from the hospital's Health Information Management department. You can do this at any time — the hospital must respond within 30 days, with a possible 30-day extension. Compare your records to your bill to verify that what was billed was actually performed or administered.
3. Review your EOB from your insurer. Identify any discrepancies between what the hospital billed, what your insurer processed, and what you are being asked to pay.
4. Write a formal dispute letter to the hospital billing department. Reference specific line items, include the CPT or revenue codes, and state clearly what you believe is incorrect and why. Send it via certified mail with return receipt.
5. Request a billing review meeting if the written dispute does not resolve the issue. Many hospitals have financial counselors or billing review staff who can walk through charges with you.
6. Ask about financial assistance. Nonprofit hospitals with federal tax-exempt status are required under IRS Section 501(r) to have a financial assistance policy and must make reasonable efforts to screen patients before pursuing extraordinary collection actions such as lawsuits, wage garnishment, or credit reporting. Ask for the hospital's charity care or financial assistance application.
7. Escalate if necessary — see the section below.

How to Escalate a Hospital Billing Dispute in Maryland

If your direct dispute with the hospital does not produce results, Maryland gives you several escalation paths:

• Maryland Insurance Administration (MIA): If your dispute involves an insurance claim denial, improper balance billing, or insurer conduct, file a complaint at insurance.maryland.gov. The MIA has authority to investigate complaints against insurers operating in Maryland.
• Maryland Attorney General's Health Education and Advocacy Unit (HEAT): The HEAT unit specifically handles complaints about hospital billing, debt collection practices related to medical bills, and deceptive billing. You can reach them at oag.state.md.us/consumer/health.htm or by calling 410-528-1840.
• Health Services Cost Review Commission (HSCRC): If you believe a hospital has billed you at a rate inconsistent with its HSCRC-approved schedule, you can contact the HSCRC directly at hscrc.maryland.gov.
• Hospital Patient Grievance Process: CMS Conditions of Participation (42 CFR § 482.13) require hospitals to have a formal patient grievance process. Ask the hospital in writing how to file a formal grievance and request a written response — the hospital is required to provide one.
• CMS No Surprises Help Desk: For federal No Surprises Act complaints, call 1-800-985-3059 or file online at cms.gov/nosurprises.