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.
Grab our free guide to understanding your health insurance costs—you can save it and refer back to it later.
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.
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, I am having a similar experience, the thing is I did two crowns in the dental clinic at my place nearby. After one year, they told me my insurance covers this so I decided to do that, but they sent an email to me and said that found my insurance didn’t cover that if I haven’t had this insurance for 6 months-12 months. So I have to pay the whole expanse for my two crowns. How should I do?
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.
Don’t pay it, fk em over.
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.
Please do!!
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.
PCP scheduled me
For an annual mammogram at a facility and I called United HC to confirm this was an “in-network” facility before I accepted the appt. I was reassured by the United HC representative after she checked my policy that it was going to be covered 100%. Well I had the mammogram, they “found something” and scheduled further testing. So I had that done as well at the same supposed “in-network” facility. Only to get bills in the mail for $795 & $690 for both procedures. (I had already paid $100 co-pay for the follow up procedure) United HC DENIED my procedures stating it was an “out-of-network” facility! When I spoke with them I explained that I double checked WITH THEM and was told I was fine. I had to appeal it and it was denied. I did a second appeal and they denied it again. Is there anything that can be done!?!?
You’ll have to reach out to the hospital and the insurance company. I’m sorry this is happening to you.
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.
if a provider is out of network is he required to bill codes to an insurance company even if he knows he will not get paid. The insurance pays for out-of-network benefits but one or two codes are not covered under the member’s plan Someone told me the insurance company has to know what the provider does even if he doesn’t get paid.
Need help
I checked myself into detox facility at the end of last year for 7 days. The clinic I originally called (in my network) sent me to a different clinic (out of network), I asked while on admissions and while at the clinic during intake if my insurance was accepted. I was told yes both times and at intake I was told I just needed to pay my deductible which is $600. Mind you, I was dealing with intense symptoms of withdrawal during this whole time. I couldn’t even read my insurance card information to admin while on the phone and I was alone during intake. My husband wasn’t allowed to come in the facility due to COVID. I got through the detox and 80 days later I get a $6,600 bill, still sober too. 🙂 So this in when I find out that the clinic they sent me too was out of network and also they I needed a referral from my insurance to be approved before getting treatment or it would cost more. I had no idea this much went into getting treatment with insurance you pay for. Can anyone offer information on this situation?
Congrats on your sobriety! Sorry to hear about the billing issue. You’ll just have to call your insurance company and talk to them to try and get it covered.
My insurance said they will pay 2 days of my 5 day hospital stay. I’ve paid my insurance premiums for years, my plan covered 100%, and I have no plan whatsoever to ever pay another dime to any doctor on this issue. Bill collectors, do your worst. Nobody’s going to answer your calls or read your mail. No one takes medical delinquencies seriously regarding credit.
The US medical system is F’d. F them back until it changes.
I went for a sleep test twice in four weeks. I was told my insurance would cover the cost.
Two weeks after the last visit I receive a bill for $19,000 .
I called the medical provider to find out why nothing was covered. Got the run around.
I refused to pay now it’s in collections. Total BS. Two tests , $19,000 that did absolutely nothing to cure my medical issue. Now I’m stuck with this $19,000 bill. What are my legal rights.
That is such a frustrating situation. You’ll have to continue talking to the clinic and the insurance company.
So my daughter was in the er for pain and fever in 2019. Stayed for observation less than 24hrs. The insurance company states on the eob that the dx used was a non covered dx under our plan. I have not received a bill but the insurance claim states there is no out of pocket money due. It was paid by a third party payer. What is a third party payer and if the claim states no patient responsibility can I put this to rest as no payment is needed from her.
You can most likely put it to rest.
Wonderful blog…hoping maybe you can point me in the right direction. I left my job on 2/19/2021. Went to my Dr the following week and also for my yearly mammogram before my insurance ran out. I’m being billed for lab costs for a mole the Dr had removed and had sent to the lab. Also, the mammogram showed something they needed to re-evaluate, now Im being billed for that also for non-preventive costs. Is there anything I can do about this? I am on Cobra now for my United Healthcare I had when I was employed. Thanks so much in advance.
You’ll have to call your insurance company to dispute these charges. Best of luck!
I didn’t find anything you gave advice to be helpful. Most people have already spoken to insurance company or provider as you keep telling people. What person or company or business or advocate will write summaries of medical necessity of a non coveted procedure to get it coveted and approved for payment. This is a limb and life procedure. The treatment is new and supposedly BCBS had no codes for it. Solid advice, proven outcome please.
My insurance claim was denied but I have still not received any bill from the provider. It’s $2600 for genetic testing but they told me if I fill out the survey by everymompledge within 30 day of the test it will be $300 only. I never received the survey from them. It’s been 10 months since the claim was denied and my insurance shows that I might owe $2600 to the provider. Should I wait for them to bill me or call the lab.
Avoid going to the Hospital/Medical Facility for minor injuries, try your family Doctor first or the nearest Urgent Care Facility. I learned my lesson, when I injured myself (eye) and took myself to San Gabriel Valley Medical Center/Hospital. After service you will receive two separate bills (Hospital or Medical Facility Fee & Physician Fee. A portion of my hospital bill was paid 2,243 by UHC (and accepted by the hospital), in addition to my co-pay of $125. for the first visit. My Physician fee was not. A portion was paid and I receive a bill for $751.80. because the Dr. was out-of-network. (They don’t tell you this and you can’t ask. It’s not info. they can provide.). I found out today, UHC attempted to negotiate with the Dr. (not in his contract to negotiate – refused). Back on the phone with UHC, and working with them to handle this matter. Going forward avoid hospital settings, go to urgent care. Do your research, ask questions and avoid the high fees.
I worked for a Doctor’s office for a few years. UHC was the hardest insurance company to work with. They rejected most claims the first time. Then our office would resubmit the claim. Usually rejected again. I seriously believe that they hoped it would not get resubmitted. Then when you had to call them, it was hold forever. We finally stopped taking UHC insurance. After it is rejected, it is really the patient’s responsibility. I believe that most hospitals and HCP want to help you, so they get paid. You may have to take a day and just wait on hold. There are times your benefits department at your work can help as well. Their agent doesn’t want to lose their account. The other thing is to make sure to ask questions of the office and make sure that the Doctor is in your network. I get a list every year. If worse comes to worse, you can always contact state agencies that oversee these things. Many times, it just takes persistence and talking to the right person to get it taken care of.
Dental office did not bill my insurance at time of service and waited for over 15 months. Insurance denied coverage due to length of time between service and billing. Now dental office is billing me for entire amount. I thought that my insurance had paid since I haven’t received a bill from the dental office during this time. Do I owe this amount to the dental office?
You should call the dental office and see if you can resolve this. You should not have to pay the full amount.
I had an acute asthma attack/breathing issues and went to the ER. The doctor advised me that he wanted me to be admitted while they determined what was causing the breathing issues and to rule out pneumonia or a viral cause. Now insurance company is saying admission was not medically necessary and is denying the $7,000 inpatient care bill. Hospital has sent me a bill. Am I going to be stuck paying this bill? It’s not like I volunteered to get admitted, I was following doctors advice.
You should call the insurance company. If needed, you could have the doctor let them know it was medically necessary.
This is due to the failure of clinic staff to faithfully perform their work on insurance claims. It’s not my fault. That happened 3years ago. Do I have to pay for the clinic staff fault? For that reason ,can the clinic refuse treatment? The clinic said “There’s nothing about negotiation for the payment “E
hello. I from california, I have 2 health insurance. 1 is kaiser silver 70 plan. 2. is bluecross
ppo 1000.
I went to las vegas travel, and I have stomach flu, I went to emergency hosipal.
after i went back california. I call my health insurance, they said not cover out of net work, when i buy health insurance no one tell out net work. can you help me , how to do. thank you.
Typically the only out of state care plans cover is emergency care.
Happy New Year! I have one that you might not have answered before so I am hoping you can help me. Lately we have been experiencing lots of denials for no auth/referral on our PCP claims. Yes they are HMO plans and I’ve noticed that the patient is not seeing their normal PCP so now we are stuck writing this off. What happens if they go to our Urgent Care and see a PCP there? Our issue is its a POS 11 Urgent Care and not a POS 20 Urgent care. Is there anyway of salvaging these denials? Thank you for your time
My wife had a stroke. She was taken to ER in Sutter Health / Cal Pacific Med Ctr facility #1. They had no beds, so they transported her to the ICU in Sutter Health facility #2. Now Blue Shield is saying the facility is “non-participating.”
I did not choose either facility. How much they’ll be willing to pay, but I’m sure it’ll be much less than the ICU charge. How can I handle this to ward off a disaster before it’s too late?
So sorry to hear that. You’ll have to talk to your insurer.
I had surgery for a torn rotator cuff and with that and my PT, my bills came to roughly $27,000. My insurance company won’t pay my bills and I cannot find an enforcement agency to make them uphold their end of the bargain. The excuse was “previous existing condition not covered” but I had no previous health issue when I bought the insurance in May of 2020. (the injury happened in November 2020).
When I press them to explain to ME, what MY previous existing condition is, I get no response. I am in collections with PT, anesthesia and the hospital. Who can I contact to make them legally liable for this?
Because of the Affordable Care Act, health insurance companies are not allowed to deny coverage because of pre-existing conditions. Do you have real health insurance, or are you using something like a health sharing ministry that isn’t subject to the ACA?
My company just put a plan into place that puts me in a position of having to travel 25-30 minutes+ to have any kind of coverage. If I have an emergency and I die on the way to the covered hospital (instead of being able to go to the hospital 10 minutes away), can my children sue the employer?