Emergency rooms do not wait for an adjuster to call you back. They treat first, code the visit, and bill hard. If you were hit while walking, you already know the bills arrive fast, messy, and with numbers that make no sense. I have sat at kitchen tables with clients holding a stack of ER invoices, transport charges from the ambulance contractor, imaging fees from a radiology group they have never heard of, and a “facility fee” that looks like a car payment. The driver’s insurer says they are still “investigating.” Your own health plan denies the claim as “third-party liability.” Meanwhile, collectors dial nightly.
This is the gap where a pedestrian accident lawyer earns their keep. Not by waving a wand, but by coordinating benefits, forcing coverage to flow in the right order, and pushing back on hospital pricing, coding, and lien claims so you keep the settlement you deserve. The law provides levers. Insurers count on you not knowing how to pull them.
The first 72 hours: what matters most
I always ask for the first three documents: the police report number, the hospital facesheet, and the Explanation of Benefits (or denial) from any health plan. Those three tell me who is likely primary, where the bills are going, and whether the adjuster is already framing fault. If you do nothing else, do these quickly:
- Request your hospital records and itemized bills, not just the statement total. Ask for CPT/HCPCS codes and diagnostic codes. Itemization exposes billing errors. Report the crash to your own auto insurer if you have a policy, even if you were a pedestrian. Ask about MedPay or PIP limits and the process to submit bills.
That short list avoids the two most expensive mistakes I see: letting the hospital steer billing exclusively to the at-fault driver’s insurer, and waiting for liability acceptance before you route care through coverages you control.
How ER bills get so high so fast
Hospitals set chargemaster rates that few patients ever pay, but those rates drive initial invoices. In a pedestrian crash, I commonly see:
- A Level 4 or Level 5 trauma facility fee, often between $3,500 and $10,000 for the room alone. CT scans billed separately by the facility and the radiology group, doubling the surprise. A head and cervical CT can total $2,000 to $6,000 at list price. ER physician fees billed by a staffing company, not the hospital. That invoice arrives weeks later, leaving you to think the hospital bill covered everything.
Charges escalate when coding lists “trauma activation” or “critical care” even if you were stable after triage. Sometimes justified, sometimes not. Without itemized codes, you cannot tell. A pedestrian accident attorney reads these like a mechanic listens to an engine, looking for the off notes that suggest an unnecessary test or upcoding.
The insurance shuffle: who pays first and why that order matters
The at-fault driver’s insurer should ultimately pay for your losses. That is liability coverage. It does not pay as you go. It pays at the end, in a settlement or judgment. While you wait, other coverages can and should step in.
- MedPay or PIP under your own auto policy. These pay medical bills without fault findings, often within days. In MedPay states, limits range from $1,000 to $10,000 on typical policies, but I have seen $25,000 and above. In PIP states like Florida or Michigan, statutory structures apply and deadlines are strict. Use it early to keep accounts current and avoid collections. MedPay usually has no subrogation against you if the policy says it is “excess,” but read your policy or have a lawyer do it. PIP carriers do assert reimbursement rights in many states. Health insurance. Yes, your health plan still applies to injuries caused by someone else. Plans often send “accident questionnaires” and delay payment until they identify a third party. Answer the questionnaire promptly so claims do not pend forever. Health plans negotiate rates, so a $12,000 ER bill might contract down to $3,800. Even if the plan has a reimbursement right from your settlement, negotiating that lien is far easier than negotiating the gross bill later. The driver’s liability carrier. Accepts or denies fault, reserves rights, and rarely pays piecemeal. If they do issue partial payments, those payments are voluntary and usually count against the eventual settlement. Do not sign broad releases to secure a small check for a big hospital bill.
Coordinating those coverages is half logistics, half leverage. When I see a client’s ER bill routing only to the at-fault insurer, I intervene. We reroute to MedPay or health insurance to secure contracted rates, then preserve the lien resolution process for later.
Common insurer excuses, and how to counter them
I keep a mental library of phrases that signal delay or denial. A few greatest hits, with the playbook response:
“We are still investigating liability.” Adjusters use this to pause medical payments while they hunt for comparative fault against you. If you were in a crosswalk with the signal, or even if you were not, liability does not need months of contemplation. We respond with the crash report, witness statements, camera footage if available, and legal citations to pedestrian right-of-way statutes. If they still balk, we fall back to MedPay/PIP and health coverage to keep care moving, then build the liability demand in full.
“You’re partially at fault for darting out.” This one rests on vague phrasing in the report or the driver’s self-serving statement. We analyze sight lines, vehicle speed, point of impact, and stopping distance. In urban corridors, we often secure footage from storefronts or buses. If the driver’s insurer will not engage, a spoliation letter and early preservation requests make it clear we are planning for litigation.
“Your medical bills are excessive.” Insurers cite third-party databases to argue a CT or MRI was unnecessary, or that eight weeks of PT exceeded “guidelines.” Those databases are not binding, and they often ignore trauma-specific care pathways. We counter with treating provider narratives, peer-reviewed care standards, and, when needed, coding audits showing the hospital overstated severity. Reducing a bill’s gross through coding challenges also blunts this argument.
“We need a recorded statement.” They want admissions they can stitch into comparative fault. You have no duty to provide a recorded statement to the other driver’s insurer. We offer a written factual summary with exhibits, or we defer any statement until after the medical picture stabilizes.
“Preexisting condition.” Prior back pain becomes the scapegoat for a new L5-S1 herniation. The law in most states recognizes aggravation of a preexisting condition as compensable. We document baseline function through prior records and employer notes, then track post-crash limitations and objective findings. I have resolved many claims by showing the before and after in one email: a half-marathon finish photo next to a post-crash PT intake where the client cannot sit for 20 minutes.
Hospital liens and balance billing: where cases leak settlement value
Hospitals often file a lien against your eventual recovery instead of billing your health plan, because the lien can yield more than a contracted rate. State laws vary widely. Some allow hospital liens only if the facility timely perfected the lien and complied with notice rules. Others prohibit liens when you have applicable health insurance. We review:
- Whether the hospital sent a proper itemized notice, to the right addresses, within the statutory window. Whether the hospital accepted a partial payment from MedPay or PIP, which in some states waives or limits lien rights. Whether the health plan was available and willing to pay. If the hospital refused to bill it, we argue the lien should reduce to the contracted amount.
Balance billing also creeps in. In-network ER care billed at out-of-network rates because the physician group is separate from the hospital, not your fault. Surprise billing protections exist under federal law for emergency services, but enforcement takes persistence. We make the calls, tell the billing office to flag the account for No Surprises Act review, and escalate to the state regulator when needed.
Subrogation and reimbursement: paying back without overpaying
Every dollar paid by MedPay, PIP, Medicare, Medicaid, or a private health plan comes with a potential claim against your settlement. The details matter:
- Medicare must be repaid, period. But we still audit conditional payments to remove unrelated charges. I have deleted bills for a coloscopy that predated the crash and a pneumonia visit three months later. Medicaid rules vary by state, but liens must track to accident-related care and often reduce for attorney fees and costs. ERISA plans can be aggressive. Some require full reimbursement, but not all have airtight plan language. Made whole and common fund doctrines may apply depending on jurisdiction and policy text. MedPay subrogation depends on policy language and state law. Some policies are excess after health insurance, others primary. I read the coverage provision before we promise a dime.
We approach subrogation as a negotiation. Settlement dollars are finite. If the driver’s liability policy is minimal relative to your injuries, we seek reductions based on hardship, limited recovery, and equitable allocation between economic and non-economic damages. A thirty percent reduction on a $50,000 ERISA lien is not uncommon when the facts line up.
Collectors and credit protection while your case develops
The collection cycle does not pause because you have a claim. We keep accounts in a protective posture by sending written notices to providers that liability coverage exists, that a personal injury claim is pending, and that any lien must comply with statute. We set up MedPay or PIP payments for interim relief. If a collector persists, we ask them to verify the debt and advise that any credit reporting during active insurance review could violate the Fair Credit Reporting Act standards on accuracy.
Patients often worry about their credit score more than anything. Most hospital systems now delay credit reporting for at least 180 days after the first bill, and major bureaus exclude medical collections under $500. That said, we do not trust goodwill. We document every call and letter so we can fix inaccurate reporting later.
The settlement math: why gross bills are not your damages
Insurers like to argue that your recoverable medical expenses equal what your health plan paid, not the sticker price. The law splits on this, with some states following the collateral source rule and others allowing defense to introduce the paid amounts. From a practical standpoint, we present both: the gross charges to show the seriousness of the incident, and the paid amounts to demonstrate the real economic impact. Juries respond to reasonableness. So do adjusters when they see how the care unfolded.
Pain and suffering often dwarfs the medical line items in pedestrian cases involving fractures, head injuries, or lingering mobility limits. Still, clean medical documentation supports every non-economic claim. We ask providers for functional notes, not just “patient improving.” A note that you cannot navigate stairs to your walk-up or lift your child carries far more weight than a pain scale number.
Real cases, real fixes
A client in her 60s was clipped by a rideshare driver turning right on red. ER charged $18,400, with a separate $1,900 radiology bill and $1,200 physician invoice. Hospital filed a lien and refused to bill Medicare. We sent a statutory notice demanding the hospital submit to Medicare under federal secondary payer rules. They complied, Medicare paid around $2,700, and the lien dissolved. Later, we repaid Medicare $2,700 less the procurement cost reduction. The liability carrier’s $50,000 policy tender became a net recovery that actually helped her, rather than a pass-through to the hospital.
Another case involved a college runner struck in a crosswalk at dusk. Adjuster claimed “dark clothing, partial fault.” We pulled bus cam footage that showed the driver on a phone mount, head down. Liability resolved. The hospital coded critical care for 60 minutes despite stable vitals. An audit revealed duplicate trauma activation codes. Facility fee dropped by $5,600. PT extended to 14 weeks raised eyebrows at the insurer, who cited utilization guidelines. We obtained a therapist letter tying prolonged rehab to a bone bruise in the tibia and compensatory gait affecting the hip. The adjuster moved off the cap. The client finished the next semester without a limp.
Rideshare, delivery vans, and trucks: policies and pitfalls
Pedestrian impacts involving commercial vehicles change the insurance math. A truck accident lawyer reads the Federal Motor Carrier Safety Regulations first, because defects in logging or maintenance can drive a larger settlement. In rideshare cases, the coverage depends on app status: offline, en route, or with a passenger. Uber and Lyft maintain third-party liability coverage that can reach seven figures in active ride phases, but they dispute coverage if the driver toggled off moments before the crash. We subpoena telematics and app logs early. Delay risks data loss.
Commercial auto carriers challenge medical necessity even harder than personal lines. They often send you to an “independent” medical exam. We prepare clients for these, because one offhand comment can frame the narrative. If they claim MMI early, we counter with treating surgeon notes and, where appropriate, a second opinion from a specialist in pedestrian trauma. When the stakes climb, so does the need for documentation that anticipates the defense.
When the pedestrian is partly at fault
Crossing mid-block, stepping out from between parked cars, walking against the signal, all become fodder for comparative negligence. The law in your state decides how much fault bars or reduces recovery. Modified comparative systems may cut you off at 51 percent. Pure comparative reduces your award by your percentage.
I do not accept the insurer’s fault split as gospel. We test it. Speed matters more than many realize. A 10 mph reduction in speed can be the difference between a collision and a near miss. If the driver exceeded the limit or failed to scan properly, fault shifts. Lighting, sight lines, and vehicle design also factor. Pedestrian crashes often involve SUVs whose front profiles cause more severe injuries at the same speed. Juries get that. So do adjusters when shown the right evidence.
Getting care without wrecking your claim
Continuity of care is not just good medicine, it is good evidence. Long gaps between ER discharge and follow-up look like the injury resolved, even if you stayed home because you feared the bills. We address that by lining up providers who accept your coverage, or by issuing attorney’s letters of protection where appropriate. I use LOPs sparingly, because they can inflate billing and trigger defense attacks. But when used with credible providers and careful oversight, they preserve function and paper the record you need.
If you have a primary care physician, involve them early. They contextualize your baseline health and coordinate referrals. Keep a simple symptom journal with dates, activity limits, and medication effects. Adjusters discount vague discomfort, but they understand that a two-block walk now requires rest, or that shifts longer than four hours trigger swelling and pain.
Negotiation timing: why patience pays
Quick settlements help insurers, not you. The full scope of a knee injury can take months to emerge, especially if conservative care fails and arthroscopy becomes necessary. Settling before maximum medical improvement hands the insurer a discount. We calendar reassessment points and only issue a demand when your providers can project future care and realistic recovery. If a limitations period approaches, we file suit to preserve the claim, then continue medical development.
When we do send a demand, it reads like a story backed by receipts, not a spreadsheet of codes. We include short videos when available: you on crutches navigating stairs, or the intersection sight lines at rush hour. Facts and visuals move numbers more than adjectives.
Choosing an advocate who understands pedestrian medicine and insurance
You will see a lot of titles online: car accident lawyer, auto injury lawyer, personal injury attorney, pedestrian accident attorney. The labels overlap. What you want is someone who handles pedestrian cases regularly and knows how ER billing, PIP/MedPay, health plan subrogation, and hospital liens collide. Truck or rideshare variants add complexity a generalist might miss. If your crash involved a semi, a truck accident lawyer with FMCSA experience matters. If it involved an Uber or Lyft driver, a rideshare accident attorney who has wrestled with app status disputes saves months.
Searches like car accident lawyer near me or best car accident attorney bring up paid ads. Ask specific questions instead: How do you handle hospital liens? What is your plan if my health plan is ERISA self-funded? Will you audit coding? How many pedestrian claims have you taken to verdict in the last five years? The right injury attorney should answer without fluff.
What a good lawyer does behind the scenes
A lot of our value is invisible. We set the case foundation early: notice letters to preserve camera footage, requests to transit authorities for bus or streetcar video, spoliation letters to rideshare or fleet owners for telematics, and traffic signal timing data from the municipality. We work the medical side: coding audits, in-network routing, lien management, and subrogation reductions. We blunt adjuster tactics by building a record that resists simplistic attacks.
That behind-the-scenes work shows up in your net recovery. A $125,000 settlement is meaningless if liens and inflated bills consume it. The goal is money in your pocket after fees and medical claims, along with a plan for ongoing care. That requires judgment calls along the way: whether to use a letter of protection, whether to push a provider to bill health insurance, whether to accept an early policy limits tender when the liability exposure is clear and the assets are thin.
Practical steps you can take today
- Centralize the paper. Create a simple folder, paper or digital, with ER records, imaging discs, billing statements, and insurance letters. Keep envelopes with postmarks. Redirect billing. Call the hospital’s patient financial services and ask them to submit through your health plan and MedPay/PIP. Provide claim numbers. Ask for an itemized bill with CPT codes. Freeze the narrative. Write your own short account while details are fresh: positions, weather, clothing, traffic flow, where you looked and when you saw the vehicle. Sketch the intersection. Your memory today will beat your memory six months from now. Identify cameras. Walk the route in daylight and look for doorbell cameras, storefront cams, and traffic poles. Note business names and addresses. Time kills video. Get a consult. A personal injury lawyer who focuses on pedestrian cases will usually review for free. Bring the itemized bills and your insurance cards, including auto.
Final thought
Pedestrian crashes sit at the crossroads of trauma medicine and insurance games. Hospitals lean on liens. Health plans posture for reimbursement. Liability carriers stall, nitpick, and discount. None of that is inevitable. With the right sequencing of MedPay or PIP, assertive use of health insurance, disciplined review of coding and liens, and a fact-driven liability presentation, you can turn a stack of ER bills and insurer excuses into a recovery that pays for real healing. Whether your case calls for a pedestrian accident lawyer, a car crash lawyer, a truck crash attorney, or a rideshare accident lawyer, the skill set is the same at its core: know the medicine, know the coverage, and never leave money sitting in a billing code.