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Health Insurance Print

What if Your Doctor Says Insurance Will Cover Something and Then Insurance Doesn't Pay the Bill?


My doctor left me a voicemail that said “you’re in danger of sudden death syndrome.”  He recommended I have a procedure right away.  Even though I was scared, I was very thorough in our follow-up conversations to make sure the procedure he recommended was right for me. He assured me that since this procedure was a “gold standard” that my health insurance would cover it. A month after the procedure, my health insurance sent me a letter that said the procedure was ineligible for coverage and they needed more information before paying. They requested access to my medical records to get the information they needed. I’m very worried that I’m stuck with the bill and feel like I have a lot of work ahead of me to get this resolved. What should I do? - Lucinda


That is a very scary situation and we hope you are feeling better (at least physically). While we could write about your doctor communicating better on your test results, we’ll focus on your insurance problem at hand. We find that a lot of patients go through sticker shock after finding out their health insurance company expects them to pay an enormous medical bill. When under this stress some patients have thrown that letter and their bill into an attic, garage, or under the bed, and ignored it until they got a warning letter from a bill collector a year later. BUT your health insurance hasn't denied your claim yet. AND there are a lot of small steps you can take to fix the situation before it gets that far.

First Step: Find Out Why Your Health Insurance Company Needs Information

Call your health insurance company first to get more information about the letter they sent. If you know why they are thinking about denying your claim, then you can figure out your next steps.

There’s no need for your health insurance company to have full access to your medical records. Giving them this privilege might work against you in the long run, so find out exactly what information they need and why they need it. They are required to explain why they are denying your claim. Or in this case, thinking about denying your claim. 

Second Step: Talk to Your Doctor’s Office

Some doctors refuse to deal with health insurance issues, but most will try to help out in some way. Let your doctor's office know about the letter you received and why your health insurance might deny the claim. Roughly 9% of all medical claims are denied by insurance, so it’s almost certain your doctor's office has dealt with this same issue before.

Talk with someone in the office who deals with health insurance problems regularly (e.g.,possibly the practice manager or billing coordinator). They might be able to fix the situation simply by using a different medical billing code. If you decide to give medical records to your health insurance company, work with this person on filling out the form properly. (It might be easier to do this in person). They can help you provide just the information needed to handle this claim without granting rights to all your medical records. This will help you fix the situation while still protecting your privacy.

Third Step: If Things Get Complicated

You might become a mediator between your doctor and your health insurance. If you become overwhelmed by the process, there are professionals you can contact to help you:

  • Patient Advocates: A patient advocate who specializes in medical billing disputes can take over the process for you. They can make calls between the doctor’s office and your health insurance company to help settle the problem. Prices vary for their services, so make sure to ask about costs up front and don’t be bashful about shopping around for the best price.
  • Medical Billing Advocates: There are companies who have streamlined the process of negotiating medical bills. Look for one who handles insurance disputes.

It's a bit clunky, but you can find these services in the The Alliance of Professional Health Advocates Directory. Look for someone with the right specialty and who works in your area or can work nationwide.

Important Reminder:

You are not alone. This may take some time. There are many ways to fix this without you footing the bill. We’ll continue answering any questions you have as you work your way through this process. More than likely this process will take less than a few months, but if it’s a complicated situation it could take as long as a year.

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If you have a question like Lucinda's that you're struggling to answer, email us here! We will help you get started on the right path.