What to do when your health insurance doesn’t pay for a medical service
Insurance can be complicated, and medical billing can be even more difficult to understand. Most people would prefer to just go to the doctor’s office, have insurance take care of all the payments in the backend, and never think about the bills again. Unfortunately, insurance doesn’t always cover everything. What happens then? Here are the things you should understand about health insurance claims in order to avoid unexpected medical bills, plus a guide on what to do if your health insurance won’t pay for a medical service.
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How does insurance and paying for my medical services work?
There are volumes and volumes of books on how insurance and medical billing works. While there are nuances, here’s the basic outline of how it works.
Your health insurance plan offers coverage of certain healthcare services and treatments, and it outlines how much it’ll pay for each service and how much you’ll be responsible for. Provided that you have a managed care plan, which most Americans with health insurance do, your plan will also provide information as to which healthcare providers and facilities are in-network. Always ask to understand what insurance will and will not pay for, and how much they’ll pay for, before visiting a healthcare provider.
After you visit a healthcare provider that accepts your insurance, they’ll typically file a claim on your behalf. Your insurance company already has set rates that they’ll pay out for each type of service, and they’ll pay your provider that amount regardless of how much the provider has listed in their claim.
If your healthcare provider is in-network with your insurance plan, then they’ll simply zero out the balance. If they’re out-of-network, however, whatever the insurance company does not pay for will be billed to you. This is why you may still receive medical bills after insurance pays its portion of your costs.
It’s also possible that the claim will be denied completely and you’ll end up with the entire burden of the bill. If your insurance company decides to deny the claim, it must notify you in writing as to why your claim is being denied, and it must do so in within certain time frames (this depends on the type of claim). It must also provide you with information about the appeals process.
Why would health insurance not pay certain claims, and what can I do?
There are many possible explanations as to why your health insurance company may not pay certain claims. Here are the four main categories of reasons, along with suggested action items:
1. Human error
It’s possible that your insurance company made an error in processing your claim, or perhaps they gave you misinformation that led you to make a doctor’s visit or undergo a treatment that isn’t fully covered. Or maybe your healthcare provider billed your visit incorrectly. One example is when a well-woman visit that is free, preventive care is categorized as a specialist visit to the gynecologist. Medical billing is complex and can be error-prone, so call your healthcare provider and insurance company to try to rectify these errors first, and then go through your insurance company’s appeals process if necessary.
It’s also possible that your insurance company required additional information but either your provider did not provide it or the information got lost during processing, leaving your claim hanging. While this may not seem like your fault, the burden is on you to follow up with your insurance company and your healthcare provider to make sure all the information needed is provided and processed so your claim can be paid.
2. The provider is not in-network
While many people think that a healthcare provider accepting their insurance is the same as being covered, it’s actually not. To avoid getting an unexpected medical bill in the mail, you also need to verify that this healthcare provider is in your insurance plan’s network. If a provider accepts your insurance but is not in-network for your plan, it means they will bill your insurance company for the service and then charge the balance of what insurance won’t pay for directly to you. If you have a PPO plan, this typically means paying higher, out-of-network costs. But if you have an HMO plan, you may be stuck with the entire cost of the visit. Note that it’s important to determine whether your healthcare provider is in-network with your specific health insurance plan, as insurance companies can have several plans with different provider networks. Make sure to get this confirmation directly from your insurance company, not via your healthcare provider, as the insurance company has the final word on what gets covered.
3. Bundling
Another type of misunderstanding that can occur is one between your healthcare provider and your insurance company, something known in the medical billing industry as “bundling.” Bundling is when a secondary procedure is considered part of a primary procedure. For example, if an incision is required before a certain surgery, your insurance company may “bundle” the two procedures together and only pay out one claim. However, your surgeon may bill the incision and the surgery separately, thus leaving you with the bill for the incision claim. Because these bundling cases are mired in medical billing codes and jargon, it’s worth considering consulting a medical billing professional to help you dig through it.
4. Lack of pre-approvals/referrals
Some plans require referrals or other pre-approvals to see a specialist, and if you get your medical care without this pre-approval, it’s possible that your insurer will deny your claim. If this is the case, make sure to get a referral immediately so your future visits are covered, and see if your past claims can be reimbursed now that you have a referral. If not, you can appeal via your insurance company’s official process.
Most plans will also only cover medically necessary care, and your insurer may deny your claim if they feel the service wasn’t medically necessary. If this is your situation, you can ask your doctor to submit a “Medical Necessity” form on your behalf (or any other information requested by your insurance company).
5. Your insurance does not cover the medical service
Lastly, it’s possible that your medical service was simply one that is not covered under your health insurance policy. There are always exceptions, so speak to a representative of your insurance company to understand why your care was not covered and try to appeal it if you feel like an exception should be made.
What are some common medical treatments not covered by insurance?
Coverage varies heavily depending on policy, but most health insurance plans do not cover the following procedures:
- Adult dental care.
- Cosmetic surgery.
- Fertility treatments.
- Long-term care.
- Private nursing.
- Weight loss surgery.
You can find out what is covered by your health insurance plan by reviewing your plan’s Evidence of Coverage (also known as Certificate of Coverage) and speaking with a representative of your insurance company if you have further questions.
What can I do if I’m stuck with a bill that health insurance won’t pay for?
If you’ve already tried appeals and other tactics mentioned above and are still stuck with a medical bill, you can try to fight your bill or reduce the burden through various tactics.
One way is to learn how to negotiate medical bills with insurance and healthcare providers. You can work with them to negotiate an interest-free payment plan, a discount for immediately paying the balance, or another compromise solution that will help you pay your bills without them being sent to the debt collectors and damaging your credit. To help you negotiate, you can use tools such as Healthcare Bluebook to determine the fair price of various treatments in your area. You can also ask and see if there’s any sort of financial assistance program; many hospitals have them.
Another option is to work with a medical billing advocate who can reduce your costs by looking for abusive, fraudulent, and erroneous billing practices. While it may sound outrageous, industry estimates say approximately 80 percent of medical bills have errors. Many medical billing advocates will also negotiate with healthcare providers on your behalf.
Whatever you do, make sure to be persistent but polite, and keep good documentation of your efforts, including the date and contact info of each person you speak with. And don’t procrastinate on having these conversations. Once a bill gets sent to the debt collectors, not only does your credit get damaged, but the bill is also effectively out of your healthcare provider’s hands, making it much harder to negotiate.
How can I switch insurance plans?
You have several coverage options.
- Marketplace/“Obamacare” plan. You can enroll in a Marketplace health insurance plan, also known as Obamacare or Affordable Care Act insurance. See plans and prices here.
- Medicaid. You also may be eligible for Medicaid, depending on your income. You can see if you’re eligible and apply here.
- COBRA. If you’ve been laid off recently, you usually have the option of COBRA, where you pay the full premium of the same insurance your employer purchased for you. COBRA is typically much more expensive than Marketplace insurance, but it allows you to continue the coverage you already had. Learn more about comparing COBRA with Obamacare health insurance.
- Medicare. Once you turn 65, you’re eligible for Medicare. Call us to enroll at (855) 677-3060.
You can enter your zip code below to see if you’re eligible for Medicaid or a subsidy to lower the cost of Marketplace insurance.
If you have questions or need help enrolling, you can call us at (872) 228-2549.
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I’ve been going to a pain management Dr. And they require a urine test and my insurance just informed me they won’t pay and pain dr. Is charging me 500. Per test and they say I owe 9000.00 so far
That’s total BS. A unite test costs maybe $20-$40 max.
Your pain doc is a crook. Report him to the medical board and your insurance company. He’s billing things separately and you can nail his butt to the wall.
Find a reputable Dr. unless you have something to hide.
It’s approximated that $3 trillion worth of medical claims are submitted every year to insurance companies, etc., with $262 billion worth of these claims denied. Approximately 65% of the denied medical claims are not resubmitted to the organization which denied the claim. Statistical data indicates that commercial payers are denying 58% of those claims.
Appealing against denials can eat up a lot of time and money, hence a good bit of health providers find it impractical to appeal against denied medical claims. Additionally, it can be a real burden to create a denied claim reduction program (within their medical billing process). This is due mostly to the extra manual processes, work and pressure stacked on internal resources.
I am having the bypass surgery on the 18 of November and my Insurance approve the surgery. I recieved a letter from my Insurance company that in January 1, 2020, my insurance (IllniCare Health members. Will IlliniCare still pay the bill?
What dd the letter from your insurance company say?
I抦 not that much of a online reader to be honest but your blogs really nice, keep it up! I’ll go ahead and bookmark your website to come back later on. Many thanks
What happens when your insurance company, Adventist Health, does not have the doctor you need for your surgery other than one that is out of state?
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It’s difficult to find knowledgeable people for this topic, but you seem like you know what you’re talking about! Thanks
My Provider and his office admin (small office) told me about a year ago that my ins co took back payments because (Tufts) thought I had ins coverage with a former company (Anthem). I did not, for the time period in question, and proved that to both ins companies and my Provider with a letter showing my period of coverage, which I received from Anthem. The problem is that Tufts still has not paid back the money the took from my Provider. My Provider is, and has been, asking me to pay back the money that was taken back from them. I don’t think this is fair and I told the Provider that I did the initial legwork and they need to take it from here. This is actually what Tufts told me needed to happen. Other issues that happened – the Provider never attempted to file an appeal even though they had Prior Auths, and the office informed me they switched software programs after this happened and did not have any of the records of my bills/claims any longer. They apparently kept no back up or hard copies. Is it my legal responsibility to pay these payments to my Provider? Thank you very much for your help, Frustrated Patient
Hello! Sorry you’ve had such a frustrating experience. You’ll have to contact your insurance company and the provider for more info.
hi,
my insurance is not going to pay for my father diabetes bill came from hospital ER. Its really high and i am shocked at the bill !!! and i cant afford to pay it. Please suggest what can i do here ?
Sorry to hear that. You can try negotiating with the hospital to see if they’ll reduce the bill.
sas,
Just don’t freaking pay it. Send your copies of everything you have and request your complete file from the Dr. The Dr.’s office is required to keep complete files, including billing information. Every piece of paper, test result, office note, prescription information, and miscellaneous MUST BE KEPT IN THE FILE BY LAW!!
I think your Dr. will be more than willing to work with you to get him paid and you off the hook!
Shame on Tufts for having “no info.” I would have the same chat with them and get your complete file from them too!
Owned and was the CEO of a medical office for 2 years. I know the rules, the law, etc…maybe I should start my own blog with real and useful information and the steps to follow to resolve issues!
Yes, please do. You could become a medical billing advocate and charge for your personalized services.
Superb read, I just passed this onto a colleague who was doing a little study on that. And he actually bought me lunch because I located it for him smile So let me rephrase that: Thanks for lunch!
My daughter gave birth nearly 2 years ago on December 31st 2019. She has Blue Cross Blue Shield and so far they have refused to pay for this birth. She had Invested in to a health care account to cover all the expenses except for the $4000. She only has perhaps 20% of that bill that she owes. Her Cern is that they will turn this over to credit and destroy her hard earned credit Talked to a few people at the hospital as well as the patient advocate and she is getting the run around who exactly should she talked to or is it time to get a lawyer
I’m sorry to hear that. All Marketplace plans should cover maternity care. Have you tried talking to a medical billing advocate? They may be able to help.
If your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party. You can ask that your insurance company reconsider its decision. Insurers have to tell you why they’ve denied your claim or ended your coverage.
i was preapproved for surgery 3 times my ins payed first and last surgery 1st 2012 2nd 2014 and 3rd 2015 the 2014 was turned over to a collection aggence it was 23000.00 hired a lawyer to help me everything was fine never heard anymore about it. Then in 2019 got a letter in the mail from the collection to be at court to resolve the bill got to court and it was nolonger 23000.00 it is know 40000.00 judge is making me pay it by gurnishen my pay and taking my taxes im loosing everything I”ve worked for the last 24 years please help me figure out what went wrong plus my job fired me the day my docter released me to goback in 2015 said fmla ran out and i was paying extra for short and long term ins incase i ever got hurt for 14years how does this happenPLEASE HELP somone
I’m really sorry to hear that. You’ll have to speak to a legal professional about the details of your case.
Thats sounds great. Need all the help I can get.
Love your blog, do you have a YouTube Channel as well?
We do have a YouTube channel – https://www.youtube.com/channel/UC2NNmKDY34cGj9cuRkLWbjg
I received a pre-authorization letter from my insurance for a procedure and a shot that the provider requested for the procedure. The provider is in-network. They billed the insurance for the procedure but not the shot. Now, they claim that the insurance won’t cover the shot, yet they never billed them. I requested the itemized bill myself and submitted a claim to my insurance. What can I expect? The provider is asking me to self-pay this shot, but I am not ok with them not billing insurance. Any reason why they won’t bill them, esp. since they are in-network and it was pre-approved with the same codes as in billing?
You’ve done the right thing by submitting the claim directly to your insurance company. I’m not sure why they wouldn’t have attempted to bill the insurance company, especially since you already had the pre-authorization letter.
I have a medical supply company that I buy ostomy supplies from. My insurance has always paid on the claim. This last order I got they denied this time and it is the same thing I always get. They claim the company is not participating. How can this be when they have accepted allyear? What do I do now?
We’d recommend you call your insurance and call the medical supply company to make sure they have actually stopped participating. You can also work with your insurance company to find a medical supply company that will be covered.
We have a max out of pocket of $9000.00 family HDHP; in 2019 my wife had some heart issues and everything she did was pre-approved and of course in Network-we wound up paying $3800.00 out of pocket.
I wound up with Salmonella in 2019 also; went to ER of an in network provider wound up being hospitalized for 2 days plus the ER time-
The hospital billed the Insurance and the Insurance paid some and left us with 7800.00 to be paid to the hospital; well I’m no genius but $3800 plus $7800.00 equals $11,600; plus other bills we’ve paid in 2019.
The hospital nor UHC are doing anything to help us even though we’ve proven over and over that the cost they are putting on us is not right.
I have appealed-filed grievance and no one will do a damned thing. To top it off the hospital keeps coming back with more and more charges and it never stops.
One bill today was stated that I owed $999.62 paid it in full and the online statement said I owed another $46.00 after that.
Its criminal whats going on- I hurt my back 9/25/2020 went to the ER they gave me morphine-dilaudud and percoset and Zofran all via IM. The itemized statement said via IV and charged a level 5 visit-the doctor spent maybe 3 minutes total and I never received an exam nothing; just told to ice and rest my back.
The hospital is charging $4800.00 for 45 minutes; un freaking real and we can’t get anyone to do anything about.
I’m at a loss and don’t know what to do; it really is criminal what is happening to us.
I’m sorry to hear that. You’ll have to contact your insurance company–you shouldn’t be charged anything beyond your out of pocket maximum.
My dental insurance changed and my dentist no longer accepted the insurance so now they are billing me. The problem I have is that they did not ask me if it changed, I have been going there for 2 years. I also feel as if they should have checked my insurance before contacting me to make an appointment. They called me b/c we had to cancel due to Covid. Am I responsible for this bill or should have the dental company checked my insurance before scheduling my appointment??
Typically, you have to update your dentist when your insurance changes.