When Your Medical Insurance Is Refusing to Pay

Having your medical insurance company refuse payment for ANYTHING has to be one of the most maddening and helpless experiences healthcare has to offer. For those of us lucky enough to have medical insurance of any kind, we depend dearly on its support, emotionally for reassurance, and more importantly, physically for health and life itself. Having a critical diagnosis or chronic disease that demands a certain level of either acute or long term care to guarantee an optimum outcome, and being denied that care because your insurance won’t pay and you can’t afford it, speaks for itself!

Let us offer you some basic reasons for denials, and actions you can take – both proactive and reactive, to ensure the best possible outcome. No guarantees, but knowledge is power, and taking charge, even in small and simple steps can sincerely tip the scales.

  1. What you need is not a covered benefit of your plan: When your pre-authorization or claim is refused, check your policy thoroughly. It may not be, but insurance companies DO make mistakes.
  2. Missing information: If denied, they will inform you that pertinent information has not been provided. Call them immediately, clarify what’s missing, and resubmit with all the information needed.
  3. Your free annual exam was not billed as free: The ACA MANDATES a yearly free exam. If denied for this reason, this is an easy fix. This of course may not be true going forward with the current changes being made.
  4. You unknowingly received care from an out-of-network provider: exceptions will sometimes be made for emergencies, or if you can prove that NO in-network provider was capable of giving you the care you needed. Where possible, always check to see that providers and facilities are in your network.
  5. Your insurance company simply made an error: knowing your policy well, checking with the provider to make sure the coding was correct and you were in-network will give you the backup you need to correct this. Figuring it out will take time.
  6. Your provider or facility coded the treatment incorrectly: This happens frequently and once the insurance company tells you what they are not paying for, you can track that down, have it evaluated and re-coded.
  7. Your hospital stay was incorrectly coded as observation vs inpatient: do NOT sign a paper in the hospital allowing them to make you an observation patient if you need medical care. Your medical insurance may, and frequently will, refuse to pay for this stay and you will then be strapped with a hefty hospital bill. There are legitimate times when an observation status is appropriate. Always ask detailed questions, get clear answers that you understand, and double check the payment reality.
  8. Your plan does not think the test, treatment or drug is necessary: this can be hard to fight and time consuming, but it can be done. If your doctor has recommended a care plan, and the insurance is refusing to pay, enlist your doctor in helping you figure out how to rework her/his approach in order to ensure payment.
  9. Your provider accepts your insurance but isn’t in-network: the provider may accept many medical insurances, but she/he may not be in your plan’s network so ask both questions.
  10. Bundling of services: Under a bundled payment model, providers and/or healthcare facilities are paid a single payment for all the services that are performed to treat a patient for a specific “episode of care”. For example, if a patient undergoes any surgery, insurance will reimburse the hospital, the surgeon, and the anesthesiologist individually. When it is a bundled payment, the insurance will collectively reimburse the providers involved using a “set price for that episode of care”. Bundling can lead to certain parts of a procedure not being paid for if the medical insurance company feels it was not originally part of the “cost” and can engender extra bills not covered.


These are just some of the most common reasons for medical insurance companies refusing to pay for the care you need and hints on how to deal.

Your policy will clearly state the appeal process and the complaint process. Many times claims are denied routinely on the first submission. You have the legal right to appeal their decision.

Your first step should be to call the insurance company immediately to notify them that you do not accept the denial they issued. If you are going to appeal, do so immediately as many insurance companies put stringent time limits (30-40 days in some cases) to starting the appeals process after denial.

Start with your doctor. Also, many states have independent ombudsman offices and/or offer administrative assistance for people going through this process.

It is important that you clearly read and understand your policy and its ramifications for you and your family. Don’t take anything for granted, because this can let you down at a time when you can ill afford the stress of limited healthcare insurance coverage. Being blindsided is never fun.

Keep careful records, document all phone calls including the name of the person or persons you spoke with, date and time. Stay organized. Ask for a specific timeline. Develop a relationship with one agent and follow up at the end of the allotted time. Be persistent, but polite always, and if you do not get help, go up the corporate ladder and don’t take no for an answer.

Ask these important questions ahead of time:

  1. Do you take my medical insurance?
  2. Is the provider and the facility in-network?
  3. What are my out of pocket costs?
  4. What is my co-pay?
  5. Is this coded appropriately?


Honestly, this is everyone’s nightmare. Not always impossible, but aggravating, frightening, time consuming and hugely stressful. Prism Health Advocates can fight this fight for and with you. We are experienced in navigating the medical insurance and health care system, and also offer an affordable comprehensive health insurance assessment.

Post by Victoria

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