When Your Health Insurer Won't Pay

When you’re dealing with a medical condition or disease, you want to find the best treatment without a lot of hassle from your insurer. But insurers may deny coverage for the specialist your doctor recommended or send you a bill for care you thought was covered.

See Our Slide Show: 50 Ways to Cut Your Health Care Costs

One way to avoid nasty surprises is to choose a policy during open enrollment that covers the care you’re likely to need and to vet the list of in-network specialists and participating hospitals. That doesn’t mean you’ll never run into roadblocks. If you do, these steps can save you thousands of dollars while helping you get the care you need.

Lock in a specialist

Getting approval for care up front usually means you won’t have to fight for coverage later. But winning that sign-off can be tricky if your doctor recommends a specialist who isn’t in your insurer’s network. Some health plans don’t cover out-of-network providers at all. Others may provide limited coverage for out-of-network care but at a much higher cost, perhaps doubling your deductible and boosting your co-payment or coinsurance significantly.

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Before stretching to pay for the out-of-network specialist, ask your insurance company about your options. Generally, it will try to find an in-network doctor who can perform the procedure. Contact the doctors the insurer recommends and ask about their credentials, experience and proposed course of treatment. (You might also run their names past the doctor who recommended the out-of-network specialist in the first place.) Keep track of the doctors you call and what they say. Proving that you’ve covered the bases can be helpful later if you have to make a case for out-of-network coverage.

Even if you hope to work with another doctor, it’s a good idea to visit the specialist recommended by the insurer. “If nothing else, you get a second opinion,” says Tom Bridenstine, the managed-care ombudsman for Virginia, who helps state residents with coverage questions and appeals. You could decide to work with the in-network specialist after all, or the specialist might agree to write a letter explaining that you have a condition that he or she can’t adequately treat, Bridenstine says.

That happened to Robin Mullins Grunwald, 51, from Clintwood, Va. She had several surgeries for breast cancer starting in 2009, including reconstructive surgery, and her insurer paid the claims. But she ended up with an infection from the reconstructive surgery and developed a hernia. The hernia surgery was complicated because of the infection, so her doctor recommended a surgeon in Greenville, S.C., who specialized in the procedure. “I loved the doctor in South Carolina and felt comfortable with him,” she says.

When she tried to get preapproval for the surgeon in Greenville, Grunwald was denied coverage. She appealed and lost. Eventually, she got a recommendation from her insurer for an in-network surgeon in Richmond but went to Bridenstine for help anyway. He suggested she at least meet with the surgeon in Richmond. “He was fantastic,” she says of her decision to go with him. Grunwald’s advice: “Communicate with the physician and don’t be scared to ask questions.” Another piece of advice: Keep an open mind.

Look farther out

If you can’t find a doctor in your network with whom you’re comfortable, have your insurer cast a wider net, says Denise Sikora, president of DL Health Claim Solutions, in Woodbridge, N.J. Sikora specializes in helping cancer patients deal with their medical bills. She recently helped a client who needed a specific type of brain surgery but couldn’t find an in-network doctor in New Jersey with the experience she was seeking. Sikora kept asking the insurer for more in-network candidates and finally found one in Pennsylvania who specialized in the procedure.

You may have more in-network options than you realize. Kathleen Hogue, president of Mediform Inc., a medical billing specialist in Twinsburg, Ohio, recently helped a client with coverage from a small, local insurer in Ohio that gives patients access to a national network of doctors and hospitals. The client ended up going to the MD Anderson Cancer Center, in Houston, a world-renowned facility, for the price of in-network care.

If no in-network solution exists, the insurer may consider your situation a “network adequacy gap” and cover an out-of-network provider as if he or she were in network. At Aetna, for example, a precertification nurse researches the options and, if there are no in-network providers in the area who can supply the service you need, the insurer will authorize the coverage.

You don’t have to stand by while someone else makes this decision. Ask the insurer what information you can provide to strengthen your case. For instance, your insurer might be receptive to a statement from your primary-care doctor saying that he has studied the case and, for this condition, he believes you are justified in seeking treatment out of network, says Hogue.

Some people choose to go to the out-of-network specialist despite the out-of-pocket costs. In that case, try to negotiate a deal. Kirsten Sloan, of the American Cancer Society, says that some plans may agree to pay a portion of the bill at the in-network rate and have the patient pay the balance. It can help to have the physician’s office call and explain that the doctor is willing to accept in-network payment and get a preapproval, she says. Or you can ask the provider for a cash discount (see Pay Cash for Your Health Care.).

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Review the bill

You may think that all of your care was approved, only to receive a surprise bill from the insurance company. Don’t pay it until you get the explanation of benefits to find out why your claim was denied. (These forms can be difficult to decipher; ask the insurer for a translation.) The doctor may have billed with the wrong tax ID, or you may have used an old insurance card. In such cases, an appeal usually isn’t necessary, says Patrick Shea, a claims specialist and director of MedicalClaims­Help.org, in Green Bay, Wis. “You can get the errors reprocessed with a phone call.”

Coding mistakes can also cause problems. The provider’s office may have input the wrong code for the procedure or the diagnosis. “Sometimes the doctor can resubmit it with a different diagnosis and procedure code, and the charge will be paid,” says Hogue.

To spot mistakes from the start, get an itemized bill that breaks down each cost separately, especially for complex procedures and hospital stays. “Anytime you receive a bill from a facility, you should ask for a detailed, itemized bill to know exactly what you’re being charged for,” says Pat Palmer, CEO of Medical Billing Advocates of America, in Roanoke, Va. You may have been charged for services you didn’t receive, in which case you can usually fix the error with a phone call or by providing the medical records.

Fight two fronts

Kim Jacobs of Lakeville, Minn., had both authori­zation issues and clerical errors. Two years ago, she underwent an outpatient procedure recommended by her gynecologist. She had been told by the doctor’s office that the procedure was authorized, so she was surprised to receive a bill for nearly $10,000. “The doctor’s office said they got the approval, and you don’t think to double-check it,” she says. Her doctor has since written letters to the insurer explaining why the procedure was medically necessary, in hopes of overturning the denial.

In the meantime, Jacobs contacted Palmer and her colleagues for help. They asked the hospital for an itemized bill and successfully disputed several of the charges, bringing the bill down by nearly $4,000. Disputing errors on the bill is a good strategy for knocking down the cost while you’re undergoing the more complicated process of appealing. Jacobs continues to pursue her appeal with help from Palmer and her colleagues.

Win an appeal

If you decide to appeal, your case will likely go through several layers of review—first within the insurance company, then from outside doctors, and finally from the state in­surance department (or through the Department of Labor, if you’re covered by an employer’s self-funded plan). Your explanation of benefits and your insurance policy should spell out the procedure and deadlines for appeals. Sometimes you can conduct the appeal via a conference call with your physician, the insurance person who made the claims decision, and your claims advocate, says Palmer.

No matter how you do it, build a strong case. “I always prepare my appeal as if it’s the only chance I have,” says Sikora. “You have to do the research and pull it all together.”

The first step, she says, is to find out why the claim was denied. Then gather evidence and focus your appeal specifically on that reason. “I recently did an appeal for someone whose treatment was considered experimental,” she says. “We researched the drug and included about 15 research articles citing that this drug was a standard of care during the fourth stage of treatment.” The case was won on the proof in the medical record that doctors didn’t use the drug the first time—they used it the fourth time, and the treatment helped, says Sikora.

If your insurer denies your appeal, you can generally file one with your state insurance department. Californians, for example, can request an independent medical review through the Department of Managed Health Care and have the case reviewed by doctors who are not part of their health plan. “Approximately 60% of enrollees who submit independent medical review requests to the DMHC receive the service or treatment they requested,” says spokesman Rodger Butler. Find your state insurance department at www.naic.org.

The last step? Be patient. It can take several months to go through all the levels of appeal. “I usually keep the provider in the loop and ask him to keep the bill from collection while we’re working on this,” says Sikora. Keep in mind that it’s difficult to get money back once you’ve paid it. Hold out while the appeal works through the system.

Where to get help

A medical claims specialist can help you decipher your bills and appeal denials (go to www.claims.org). Most offer a free initial meeting to review the bills and complexity of the case, after which they charge $75 to $120 per hour. You can meet in person, or e-mail your bills and give the specialist permission to access your insurance-claim files online.

Also seek help and resources from advocacy groups, such as CancerCare.org, the American Cancer Society or the Arthritis Foundation. These groups can help you research commonly used drugs or procedures, and they sometimes have people on staff who will answer claims questions or help with filing appeals. CancerCare.org also has information about financial resources if your insurer won’t pay your claim and you end up with big out-of-pocket expenses.