Tips on what to do when your health insurance company denies your claim

March 29th, 2011 § 101 comments

I get asked a lot about health insurance claims. Having had many different diagnoses, surgeries, and procedures I have became all too familiar with interacting with insurance companies. In the last few years my diagnosis of breast cancer and the almost simultaneous diagnosis of our son Tristan with congenital spine and hand abnormalities has meant a level of paperwork, claims, and appeals I could never have imagined.

Navigating the maze of medical care and health insurance has become second nature to me. I think I’ve resisted writing this piece because initially I thought there wasn’t much to say. Having worked on this piece for weeks now, I realize the opposite is true: there is too much to say. Because each case is different it’s very hard to offer advice on what you, the reader, should do. But I’ve decided that’s the beauty of the blog format: I don’t have to cover all the bases. I don’t have to have all of the answers. I just need to do my best to help. And so today I’m starting to tackle this beast.

I’ve had many requests to write pieces about how to win against health insurance companies and many have suggested I go into this as a profession. I’m not sure about that one but I am definitely willing to share some of the insights I’ve learned throughout the past few years. I do think my upbringing in a medical household (my father was a cardiothoracic surgeon) helped familiarize me with medical terminology and how to correctly present a medical history.1 In addition to my tips you may be interested to read Wendell Potter’s recent advice in The New York Times: “A Health Insurance Insider Offers Words of Advice.”

Don’t take ‘no’ for an answer

The first piece of advice I have is simple: don’t take no for an answer. The fact your claim was denied is the starting point not the ending point. Insurance companies count on the fact that a large percentage of subscribers will receive a denial and either 1) forget about it, 2) intend to file an appeal but not follow through, or 3) incorrectly file the appeal paperwork (see Potter’s article, above). In any case, if they send you a claim denial and you don’t follow up for any reason, they win.

Always appeal

If you receive a rejection to a claim you feel you are entitled to always appeal. When I receive a claim denial I roll my eyes, roll up my sleeves, and say, “here we go again.” It’s what I expect, but it’s never the last word to me. Now, that is not to say that you always win– but it would take way more than one denial for me to accept that I’m not entitled to have a medical service covered. Persistence and determination are a large part of what it takes to win.

Physical (especially congenital) problems are easier to appeal than those related to developmental delays. I have little/no experience with appeals for diagnoses related solely to delays; while many of my general tips will still apply, more specific ideas will hopefully be available elsewhere online for those types of claims. I do know that when it comes to dealing with insurance companies those types of diagnoses are harder to quantify; this often leads to greater challenges with insurance appeals. In my experience, if the delays can be linked to anatomical problems, orthopedic issues, or diagnoses that can be validated with tests like MRIs or CTs, the case will be easier to justify.

Insurance companies must give you a reason whey they are denying a claim. Most often this reason is that 1) the treatment is experimental or investigational, 2) the treatment is not medically necessary, or 3) the treatment is not the standard of care.

In our case, initial denials have most often been because it wasn’t considered medically necessary.2

Show the progression of the situation and how options have been exhausted

I always try to base appeals on the phrases “medical necessity” and “medically necessary.” When you document a surgery or service that you or your family member needs:
Be clear how it is necessary to daily functioning.
Describe what will happen if what you are asking for doesn’t happen.
Be sure to tell what you have tried already, and what has failed.
Show how your diagnosis and treatment history has brought you to this place–how there is no other reasonable option to what you are asking for (or how the alternative is not preferable).
Be complete but don’t ramble.
Be sure to include diagnosis codes and treatment codes (your medical professional will provide these).

Doctors’ offices don’t always have the final say

I should point out that a doctor’s office may tell you that you will have to pay out-of-pocket. They may tell you that they have tried to get your service covered, it was denied and therefore this is the last word. It’s not. For example, my neurologist’s office tried to get my Botox injections covered. Their office appealed the first rejection. They were again denied. They told me that there was “nothing else they could do”; I would have to pay.

Undeterred, I asked for copies of my medical records. I called my insurance company and asked what I needed to do. Despite what the doctor’s office told me, I learned that patients often have a separate appeals process available to them. While physicians’ offices can often get services covered and can be very helpful in knowing what’s been a successful method of appeal in the past, they are not the only way to get services approved. In a case like this there is actually a financial disincentive for them to have insurance cover it; therefore, they may not be as aggressive as you will. What does that mean? If I had paid out of pocket they would have received almost three times the amount of money that they receive when compensated by my insurance company directly.

When the office tried to get the injections covered, the insurance company denied the request on the basis that this was an experimental treatment– not FDA-approved for this use. I provided medical history sheets from my medical file. I documented every drug I had take until that point to try to prevent migraines and the dates I took them. I explained the medical condition/situation that resulted when I had migraines. I told them how the neurologist felt the Botox might help me. I included the original letter he had written to the insurance company. I explained that if they didn’t cover this treatment a more expensive, more medically damaging situation would result– this would mean more claims and more expense for the company. In the case of the migraines I documented how much my “rescue medications” were costing them per month and how a reduction in those would easily pay for the Botox I was asking for. I showed through my history with the numerous failed attempts with other drugs that the situation had not improved and in fact the side effects from those drugs had been debilitating. I also showed the literature about preliminary success in clinical trials with Botox and my neurologist’s observations about its efficacy in others and the potential efficacy in my case. I explained I had no other choice, and while it might be not-yet FDA approved, Botox was actually on the verge of receiving such approval (I was proved right when it did receive approval for this purpose less than one year after my request).

Include all relevant information and send appeal within the required time period

This letter of appeal doesn’t need to be 3 pages long. In fact, even in my most complicated appeals I didn’t write more than a page or two at most (plus the inclusion of the supporting documents). Be sure to appeal/respond within the time frame they dictate. In the letter be sure to include:
your contact information, subscriber number, and the doctor/hospital/treatment facility information
the case reference number that they provide
all relevant diagnosis and procedure codes

Ask doctors and staff for assistance, documents

Do not be afraid to ask your doctor and his/her staff for help: what tactics have they found useful? If there are multiple codes that apply which ones are the best to use? Do they have any sample letters for appealing? What has their experience been with your particular health insurance company?

Use the rejection letter as the foundation for your appeal

Take the rejection letter you received and read it carefully. Don’t just react with “it says no” and throw it away. It is vital; in it, the company must tell you why they are rejecting your claim (usually one of those three reasons I mentioned at the outset). This is the key to your appeal. You must address this issue. They’re telling you the basis, you need to fight based on that. Be thorough but don’t get off track.

Another good example of persistence in appeals came with a corrective band we used for Tristan’s quite-misshapen head (diagnoses of plagiocephaly and brachiocephaly). The facility we used for the DOC band told us that insurance claims were most often denied for this service. Indeed, the first claim was denied; they said the “helmet” to correct his misshapen head was for cosmetic reasons only. I appealed. I explained that because of his neck abnormalities the head deformity was an inevitable result of having his head fixed in one place. Because he was unable to move his head properly he had this inevitable result of a physical abnormality. I ended up having two helmets approved for coverage.3 Had I accepted the facility’s statement that “insurance companies usually don’t pay for this” or my first rejection letter from the company, we would have had to pay in full for both helmets. I should point out that I’ve seen success getting this particular service covered even when the plagiocephaly was not due to a unique condition like Tristan’s when the subscriber persisted with the appeal process.

You can appeal more than just a denied claim

– A facility that isn’t usually in-network may actually be considered in-network for some diagnoses. For example, Memorial Sloan Kettering Hospital in New York City is a hospital that specializes in treatment of cancer. Though it isn’t normally included in coverage by some health plans, insurance companies will often allow oncology treatments there under the Centers of Excellence program. Through this policy, hospitals that specialize in certain conditions are treated as participating centers (in-network). So, if you wish to have medical care at a facility that specializes in a certain medical condition be sure to check whether they are included in this special program.

-Prescription drug plans can be adapted. This is a big one. What do I mean by this? Just because your prescription drug plan says it will only cover a certain number of pills doesnt mean that’s the last word. My prescription drug plan said only 9 pills of my expensive migraine medication would be covered each month. The problem? I frequently needed more than that number. I decided to investigate. I called my insurance company and the administrators of the prescription plan and asked how I could get that number increased because it was medically necessary for me to have more than that number. They said my doctor could call and make a request. He called and they agreed to cover 18 pills. I received a temporary increase to 18 pills a month for one year, renewable each year by going through the same process. That saves me up to $2880 a year.4

-Additionally, numbers of physical therapy/occupational therapy visits can be appealed. Our plan covers 30 PT visits for Tristan per year. He needs significantly more than that number. When the 30 are up, I write and document the medical necessity for him to receive more based on his anatomical defects. I state the skills he is getting with the visits and how they are necessary for his functioning. The physical therapist sometimes needs to include a letter and our pediatrician needs to write a prescription for the services.

Be organized. Take notes. Document everything

No matter what drug, service, surgery, or treatment you are appealing, you must be organized, take notes, and document everything. The key to my system is my medical binder. Have one for each family member. To see how to organize this essential tool, read my blogpost here.
Keep copies of your lab results, operative notes, and copies of all communication to/from your insurance company.
Be sure to have a fully documented medical history.
Save letters that were successful; if you need to repeat an appeal annually (like my migraine drugs and Tristan’s PT visits) then you will have a document that just needs minor tweaking.
Take notes on conversations (including dates and full name of the person you spoke with) at the company or doctor’s office. I learned that tip from my grandfather, a court stenographer for over 50 years: always keep track of the date, time, and name of the person you talked with. It may not be enough to prove your case, but if you can say “I spoke with (first and last name) on (date)” it lends credence to the fact that conversation took place.

Obviously, this post is not a comprehensive list of all types of conditions and how to win appeals for them. I know there are many readers who have had/will have experiences different from my own. I cannot tell you what will work for you; I can only tell you what has worked for me. I hope that by doing so and sharing some of these anecdotes you will learn something that you can apply in your own case. I realized while writing this piece over the past few weeks that there is so much to say about it. I’d like to consider this post an introduction to the topic; I will definitely revisit it again in the future.

  1. every adult should have a comprehensive medical history in their files. This should include info and dates of all hospitalizations, surgeries, diagnoses, medications. Also, you should list all close relatives and their age at time of death/cause of death []
  2. The notable exception was my petition last year to have injections of Botox for my migraine headaches covered. At that time the insurance company initially denied the claim because Botox was not FDA-approved for migraines and was therefore “experiemental.” The FDA has since approved this treatment. []
  3. They paid for 80%, we paid for 20% []
  4. With the Botox injections this number has decreased and I no longer require 18 per month []

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§ 101 Responses to Tips on what to do when your health insurance company denies your claim"

  • Pamela Carlson says:

    Persistence is a good quality to have working in a doctor’s office, too. We’ve appealed several cases to the California Insurance Commissioner, and been successful once or twice.

    Your advice is very good–and I think if more patients were organized and knew their own histories, they would get better care as well as better results with insurance companies.

    Kudos to you!

  • Miguel Rodriguez says:

    Another great and informative blogpost. I am learning so many important lessons about navigating modern life from you that I am starting to think of you as mentor (that is, if mentors are allowed to be younger)

  • AndyM says:

    Well done! I wish I had known this years ago!

  • Becky says:

    This is great advice for everyone who has or who might need to navigate the messy world of health insurance.
    Thank you, as always Lisa, for informing and caring!

  • Qinn says:

    What a great piece, Lisa! I have a feeling I’ll be referring to this often as I try to navigate my way through claims. Thank you for your fighting instinct!

  • Quinn says:

    Aaaaand my of name is “Quinn” not “Qinn.” HAHA! Perhaps lazy typos are also why my claims are getting rejected! I’m reminded of the t-shirt expression, Bad Grammar Makes Me [Sic]. SIGH!

  • joanne firth says:

    First I want to say that I’m sorry that you have had to learn such a specialized lesson. The fact that you have had to fight so hard to receive the proper coverage and are now willing to share, makes me even more grateful to know you. I didn’t think that was even possible. Having two major medical issues between my husband and myself in a 5 year period has been a financial burden we never expected. Unless people such as yourself are willing to take on these insurance companies, not taking no for an answer, the risk of being financially overwhelmed with medical expenses is high. I applaud what you have taught yourself to do. It is a daunting task to deal with all the paperwork and phone calls, especially when you are suffering from an illness. The information and knowledge you have shared here should be paid attention to by all. Healthy or unhealthy, we all need to know how to get every penny of coverage we can. Thank you Lisa for all that you do to help other people, every day.

  • Great advice, Lisa! Thanks for putting it all together in one clear piece. We’ve gone through a lot of the types of run-ins you mention trying to sort out my Dad’s insurance and care. Last year, he fell in the donut hole and Aetna wouldn’t pay for his prescriptions anymore. End of story. Not!
    Your tips about appealing and asking doctors’ office for assistance are so valid. I finally got someone on the phone who told us about Pace, which covered the cost of his scrips until his insurance reset on January 1.
    These days, the patient (unfortunately) or someone close to them has to work hard at being their own advocate.

    • Lina says:

      Andrew Bartlett: “…better rights for refugees…”??? “Better” rights? Rights exist, or else they don’t. Is there such a thing as “better” nitrogen? (And I don’t mean nitrous oxide).Perhaps instead of “better &##2t6;righ1s&88217;”, what you really meant to say was better *stuff*.It seems to me that by using such a slippery understanding of what “rights” are that you think they can be “better,” you are opening the door to a whole zany arbitrary world of legislative nuttiness. This stuff always starts out with the best intentions; next comes the stammered claims of, “but that giant mountain of skulls is not what I meant!”

      • DebVDH says:

        Hi Lisa, I didn’t want you to feel ignored. You make a good point that needs to be addressed. I simply am uniformed about the subject you are addressing. So, I’m not able to offer a viable solution for you. Maybe there is a different discipline or specialty that is better at addressing the pertinent issues you are raising. I wish you the best of luck in finding the answers you seek.

  • The day I came home from having my youngest daughter I rec’d a bill denial on an overnight stay for my 2 year old surgery a few weeks prior. I saw the giant bill and claim of “denied” across the letter and fell into a puddle of tears. I called my son’s surgeon’s office and she said, “Listen honey, they always do this. Don’t worry.. they’ll pay. They’re hoping you get upset and just pay the bill. This isn’t over.” Sure enough, a few letters later and they paid.

  • Kori C. says:

    Thank you for this post. I have just been denied a second time by my insurance company for an FDA approved spine surgery that they are claiming is “experimental.” I am only 24 and in debilitating pain on a daily basis. Your post gives me hope. I will be using it as a resource to appeal the denials myself. Thank you again!

  • Becky Randolph says:

    My son was just denied surgery three times for a Tumor in the Hypothalamus. Our doctor has had two peer to peer discussions with the doctors from the insurance company. Today, our doctor emailed us and informed us that our third appeal has been declined. FRUSTRATED

    Is there an advocate group that can help us? Do we get news channels involved? Help!

  • annabelle says:

    Thank you so much for taking the time to share your experience with everyone! Hope you never have to go through it again though. Wish you the best! I was just denied surgery (peroral endoscopic myotomy) for Achalasia. Aetna said its still experimental so I have to start my process and try to fight for my surgery. Good luck to all of us!

    • Mike says:

      Were you successful with your appeal for the POEM procedure? I am now going through the same difficulty with UMR denying the POEM surgery also. Do you have any advice or feedback about your experience?

  • […] inevitable result of a physical abnormality. I ended up having two helmets approved for coverage.3 Had I accepted the facility’s statement that “insurance companies usually don’t pay for […]

  • Veronica says:

    I had a marker test done for ovarian cancer. It came back triple what it should have been so my doctor ordered another test. I got a $300 bill, the insurance company is denying the claim as they don’t think it is an “effective test” I have never ever had blood work denied. No one ever suggested blood work might not be covered. I got a letter from my doctor and filed an appeal which was denied. I am not filing a second appeal. I understand their policy is that they don’t think it is an effective test, my argument is I had no way of knowing it was a ‘taboo” test that was on “the list” I had the blood work done in good faith expecting the insurance to cover it and unless they provide me with a list of test not covered or require me to pre certify blood work they should pay it.

  • Ellie says:

    Came across this article in a google search about insurance appeals. The most helpful thing I’ve read, for sure. Thank you very much. Do you by chance know (I’m having a hard time finding an answer) if you can appeal a denial for a procedure that you’ve paid out of pocket for? My husband is supposed to have surgery on Wednesday. On Friday night we got the letter saying that his surgery was denied. If we pay out of pocket for the surgery (a very generous offer from family, not otherwise within our ability) can we still appeal the denial? Thanks again for sharing your knowledge and experiences!

    • Sheila says:

      Yes you can appeal after the surgery has been performed and ask your Ins. company for a reimbursement of cost.

  • Health Tips says:

    Nice post. Its true many time health insurance company denies claim. At this situation many people don’t know what to do . Your post help them to take a right step. Thanks for this nice and informative post.

  • Health Tips says:

    Thanks for your article. Its very informative and good.
    Hello friends visit here for best health tips :

  • Barbara says:

    Great Information! I received my first letter from my insurance company denying to pay due to experimental surgery.
    I will appeal.

  • Beth says:

    Great info! Also, if you have employer group insurance, you are most likely entitled to detailed protections under Federal ERISA law. (Churches and Government plans are exempt from ERISA.). ERISA requires group plans to adhere to their plan documents (SPD) and affords minimal standards for pre & post service claim decisions, appeals, etc. You also have a right to civil action against the group under ERISA for breach of fiduciary responsibility. It’s a deep subject but worth understanding as it relates to a patient’s rights.

  • Lisa says:

    What if you have done this several times before and are exhausted from it. Is there a service for this? I have two more insurance denials to deal with coming up, and I’m dreading it.

  • Lisa says:

    Also forgot to say, excellent information. Thank you!

  • Holly says:

    Thank you so much for this valuable article!
    I have a question about a claim that was slightly covered. I thought my doctor’s office said that my Sleep Study was in-network only to realize that it wasn’t when I saw my EOB from my insurance. The doctor’s office said only $200 copay and now it’s $500 because it is Out of Network. I almost got a heart attack when the EOB said I would be responsible for a little over $5000 but I just received a bill from the Sleep Study lab for only $500 (they still showed that the entire cost billed to insurance was over $6000 and that my insurance only covered $1000).

    $500 copay is still higher than expected. I didn’t contact my health insurance to double check that the lab was In Network – I assumed based on what the office told me verbally.
    Is there any chance of fighting this for a lower amount?

    Thanks again for your wonderful article. I especially think that cancer patients and others need advocates to help them with all the health insurance bills/claims because it is a lot of handle even when one is healthy. If you are chronically suffering, it’s a tremendous headache to handle and constantly fight the health insurance companies.

    • Beth says:

      Why not contact the hospital, the referring provider, and your insurance? Ask them all to verify if/that the facility was not in network. Also, sometimes there is another logo on an insurance card that indicates there *multiple* networks the plan can access. But sometimes claims just don’t get processed correctly by the payer/plan. And sometimes providers just post from the remittance advice (EOB) without checking to see if a mistake was made.

      I’d also ask the ordering provider why he/she had me scheduled at a non-par facility and explain to the plan. Ask the plan if you can submit an appeal for par benefits… then solicit the ordering physician’s help. Maybe there’s a medical reason. Or maybe they just need to help you fix it. 🙂

  • Holly says:

    Oh, I am so very sorry. I see that the author of this article has passed away in March 2015. Thank you Lisa Adams for all your work. Thank you to her family as well.

  • Beth says:

    The Employee Retirement Income Security Act of 1974 (ERISA) is a Federal law that protects retirement and health benefits plans & sets standards for those who administer the plan. Among other things, the law includes requirements for the processing of benefit claims, the timeline for a decision when you file a claim, and your rights when a claim is denied.

    Under ERISA, you have the right to bring civil action against your plan. Below are some links to get familiar with ERISA, the claims & appeals process, and your rights/responsibilities. There are attorneys who specialize in healthcare law/ERISA. If you follow the rules but feel your plan has not, you may wish to consult a legal expert.

    Related to appeals, if your employer group health plan is ERISA qualified (if you work for a government or church, your plan will not fall under ERISA) see link:

    Filing a claim or appeal under ERISA:

    Best regards to you – Beth

  • Beth says:

    Oh, the Dept of Labor link for filing a HEALTH claim or appeal under ERISA:

    • Gari Phillips says:

      Hi Beth! I am reading your info on Lisa Adams page. Perhaps you can assist me?
      I have three denials and am about to go thru the ER to have my spinal surgery.

      Gari Phillips

  • Russell says:

    I’m a Brit and a long term patient(66 years and counting) of the UK’s supposed dreadful
    “socialised medicine”. I have never been denied any treatment be it antibiotics for minor
    infections right up to the present when, now aged almost 81, I am being treated for chronic lymphocitic leukemia. I pay entirely reasonable taxes to fund this care which is delivered ,as it always has been, “free at the point of need”
    P.S. I once paid to have a tooth extracted
    If anyone in the USA would like to get more info on our system do write to me at

  • Arlene Miller says:

    A loved one had a tumor removed from behind her eye. It was a keyhole operation. The surgeon removed the meniges and bone that the tumor invaded. They replaced with metal and plastic. She has sphenoid wing meningioma. The insurance won’t pay for the reconstruction because they consider it was not needed. It has to be reconstructed. Can she fight this?

  • Laila says:

    Thank you so much for your advice it really give me hope. I am just a student and i have to pay a lot for my son vitiligo treatment. Can I back and ask the insurance company to pay all my bills because they did not denies it yet, but the nurse said to me they denied them!
    I am confused!!

  • janice schreffler says:

    I have 6 denials so far as of 4-15.the insurances finds different excuses everytime to denie me. so now i go to the E,R, @ 2 0r 3 in the morning & I don’t leave until the pain stops & satifaction!

    • Gari Phillips says:

      Hi there! I am going to do the exact thing as you described.. I am going to the ER next week and have my spine surgery done that way.

  • Nik says:

    Thank you for sharing! Very inspiring too. Your words are better than some preachers and doctors – to put it mildly! Sadly, this also shows American Health Industry is too powerful yet broken. It’s about Money only; not about health at all. Shame.

    • janice schreffler says:

      Thank You for your response. Found out more info on the way. To get the medication I sadly need you have to be diagnoise with cancer & diabetic neuropothy. Thanks to the Govenor for that! Next to Obama the Govenor gotta go to.

  • Kylena Roberts says:

    My father broke his femur after surgery, he was admitted to rehab for physical therapy. He is an altzehimers patient. Upon his follow up appointment doctor advised no weight bearing prescribed additional physical therapy. He has an appointment Jan 4th and doctor anticipated to begin weigjt bearing therapy. Humanna denied services and he will be discharged Dec 24th. Humana denied because they said he has plateaued. Any ideas how we can get doctors orders approved allowing him yo remain in rehab?

  • Rita Kondan says:

    My son denied much needed spine surgery by Aetna insurance Co. He is a Police Sargeant and has been out of work for over a month. His condition is debilitating and his doctor has stated surgery is medically necessary. It is very difficult to see him in so much pain.

    Please help!

  • Tara says:

    Reading this blog has gave me the courage not to give up on a recent denile for a particular WLS. Thank you!

  • Anita says:

    I was recently denied An MRI because they whoever they are said it was not a Medical necessity. I was diagnosed with spasmodic dysphonia which is a movement disorder and the neurologist ordered an MRI of the brain becUse this is caused by nerve damage in the brain and hopefully not Parkinson’s or some other illness. I will never know now because I was denied the test . How is it that some stranger gets to decide if a test is a necessity or not. Anyone that knows this illness affects me
    Being able to speak and without speaking I can’t work or communicate , but I guess that’s not necessary . What does one do now , not only deal with this illness but no help either!

  • Jenny says:

    Thank you for the informative advice. Is this the same avenue to take when no physical therapists will take my insurance?
    Thank you 🙂

  • Troy Moody says:

    Been diagnosed with MS and insurance has denied paying any on it plaease tell me or give me ideas to fight this.

  • Donna says:

    I am trying to determine if I can fight a claim processed by insurance that they processed accepting the billed rate for an emergency room visit. My husband was in the emergency room, subsequently admitted and had emergency surgery last December. All bills (hospital, emergency room, a ton of doctors, labs, etc.) were processed, written down to agreed upon insurance rates and covered as expected…we paid the balance. He was back in the emergency room for 1 1/2 hours in excruciating pain for a complication in January, they gave him pain medicine, his surgeon advised the ER not to treat him otherwise and was referred to another specializist to see the next day. The ER doctor and subsequent specialists bills were processed as expected (write down and % covered, deductible etc.) The bill from the ER (over $1200 for 1 1/2 hours including the pain medication administered) was processed by insurance as billed (NO WRITEDOWN) and applied 100% to our deductible. I have NEVER received a bill that our PPO insurance accepted the billed rate. I called the insurance company and was told while unusual it was processed as acceptable. I asked them to compare to ER bill from same hospital for my son last September, this was written down by at least half and for my other son the previous August at an out of network hospital that was also written down similarly. (it’s been a hard year) She says it was processed correctly. I asked if it was possible to have it reviewed. NO. I asked the hospital to resubmit and was told that if it was already processed and approved by insurance they could not resubmit. Any other way to contest??

    I am very frustrated. I do know that it pays to fight. I myself had emergency surgery to remove my gall bladder years ago. Because of some bad test results they would not discharge me and allow me to consult a surgeon…..hence the emergency. Amazingly, the on-call surgeon at the hospital that is in-network doesn’t accept ANY insurance. While we looked into his ability as a surgeon we did not think to ensure he was a network doctor at a networked hospital. Long story short, emergency procedures should be covered as in-network even if out of network. The insurance company kept saying it was not submitted as an emergency, the doctors office kept saying it was. The insurance company agreed it should be covered as an emergency but could not change the way it was submitted. I had to pay to have my hospital records pulled. I had been making payments towards my bill and stopped when I realized I had already paid what would be my share had it been covered in network and continued to fight The surgeon refused to accept a lower payment and eventually sent me to collections. I finally wrote a letter to the surgeon and the insurance company and copied the state insurance board (and noted it on the letter). Less than one week later, the surgeon accepted in-network rate and gave me a refund.

  • Lisa Lylyk says:

    Hi, a patient was receiving radiation treatments and was then told to come up with $689 or the treatments would have to end because the disability insurance was exhausted. What should they do?

  • I am so interested in your articles..congratulations

  • Joseph says:

    Health insurance companies do not really care about their customers. Their job is to avoid paying as many claims as possible. It is ridiculous how much paperwork and stress and time a customer has to go through to get reimbursed. That is why in many respects the European social system is better. No red tape.

  • […] the insurance company is going to determine what medications are right for me I want to talk to a doctor. In fact I want to see that doctors medical degree. I […]

  • Lorina says:

    My mother has been fighting cancer for almost 16 years now. It recently was found in her brain. The cancer was removed. She was supposed to go to Rehabilitation after the surgery. But instead she went home. She was just tired of all the appointments and being in the hospital for so long. She thought she can do Rehabilitation on her own. Now she has lost the strength in her legs. Her breast oncology doctor said she needs physical therapy. She recently was admitted into another hospital that is not her team of doctors. They are trying to send her to hospice. They don’t understand my mother’s case. That being said the insurance is denying her Rehabilitation and only wants to pay for her to go to hospice. My mother has fought a long battle and she feels she still has the strength to keep going. We know there is no cure for cancer. But her doctors can’t give her any chemo until she gets strong again. Her doctor said there is no medical reason for her legs not being strong she just needs Rehabilitation…. what can we do…
    Desperately in need of help

  • Lola says:

    My dad recently went to the ER for shortness of breath. Which we believed to be a stroke or knew it had to do with something with his heart. They ran all kinds of tests and was there for 7 days.

    Cardiologist did tell us that he needs to have open heart surgery.

    He just received a letter from Humana Insurance that they have denied the inpatient admission. “the decision was based on: A physician review. Not medically necessary according to MCG Health(formerly Milliman Care Guidelines) – MCG-TM Inpatient&Surgical Care 19th Edition 2015: Chest Pain, ORG: M-89(ISC)

    Also, how long do you have to file an appeal. My mother had another matter denied last summer. we called they “reprocessed” the claim a few times. We received the final denial in March.

    Can someone help, suggest what to do. Do I call his insurance, hospital?
    God Bless

  • Sharon Wooters says:


    • DebVDH says:

      Hi Lisa, I didn’t want you to feel ignored. You make a good point that needs to be addressed. I simply am uniformed about the subject you are addressing. So, I’m not able to offer a viable solution for you. Maybe there is a different discipline or specialty that is better at addressing the pertinent issues you are raising. I wish you the best of luck in finding the answers you seek.

  • […] Tips on what to do when your health … – I get asked a lot about health insurance claims. Having had many different diagnoses, surgeries, and procedures I have became all too familiar with … […]

  • […] Tips on what to do when your health … – I get asked a lot about health insurance claims. Having had many different diagnoses, surgeries, and procedures I have became all too familiar with … […]

  • […] Tips on what to do when your health … – I get asked a lot about health insurance claims. Having had many different diagnoses, surgeries, and procedures I have became all too familiar with … […]

    • Linda Cotton says:

      MY husband had a tumor removed 3 months later his surgeon sent him for an MRI he gets a bill from the hospital 6 months after the MRI saying we owe over 5000 I called the insurance co. was told their was no referral from the doctor since the surgeon was the one that set up the appointment why wouldn t they have to pay ?

  • Dennis says:

    Informative tips I wish I knew this earlier. I have learned a lot.

  • Vanessa Tan says:


    Hope this article will be of help with our insurance claims.

    Miss & love you much

    Your Udie

  • John says:

    This article seems to focus on HMO providers. Does anyone know if it also applies to PPOs as well? My wife is in a similar predicament as in the article

  • Andrew says:

    Thank you for writing this. I have just been diagnosed with a life long disease and I’m very scared. My first drug after getting out of the hospital was denied! It has been a nightmare. You are a big help!

  • Maria says:

    I had a car accident in 2012, I was a front sit passager, we where stop, was red light for us, then came a big towtruck doing left turn and hit the side of the driver, was like a bomb that exploded in our car, we got in shock, panic and took long time to know that was hit by a big long truck, sense then I been suffering a lot, I take over 23 medication per day, now I have many other diseases and back neck head heart I stop breathing 22 times per hour and legg thighs feet can’t walk can’t stand can’t sit every position is bad but doctors keep saying I need treatment but my lawyer said the insurance don’t want to pay my Physio that I did for few days and 10 physiologist and I am really bad and my lawyer want to close my case and I have disc’s problems and pinch nerves and I never had that before and stomach problems and etc. I really don’t know what to do. Can anyone give me some advice please?Maria

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  • Gari Phillips says:

    Great info! Question…..
    Is insurance obligated to pay for a surgery via the emergency room should o have to go there? My lumbar surgery has been denied 3 times and my neurologist suggested I go to the emergency room and he will take care of it from there. ???? He wants me to go next week and I don’t want to be stuck with a bill for thousands of dollars!!!!!
    Thanks so much!!

  • Stacey Elbert says:

    After 10 years of having my pain manage last September a new administrator was hired and has made it his life’s mission to take me off of what he considers dangerous amount of morphine I have never had any problems overdosing or anything with my pain medication except for now having to pay for some as my doctor is completely on my side but this has gone to the point that the administrator or somebody had told the lady that opens the mail at hmsa they said if any mail comes from me to throw it out it had been resolved when the only email I was sending them with paperwork for them to send to my lawyer so that I may have him represent me this happened at least four times until I finally sent it certified mail after which my Advocate disappeared for 3 days and won’t return my calls now and I am still having to pay out of pocket with money I don’t have to be in a sort of limbo without quality of life the man told me his name is Andrew Perry MD he is a pediatrician and when I explained to him about degenerative disc disease and asked if he knew about it he replied he didn’t care what I had his only concern was getting me off of my pain medication so what does somebody do at that point the man’s already said he doesn’t care he is not following Hawaii state law as we have a patient’s Bill of Rights and a pain patients Bill of Rights he doesn’t even follow their own handbook claiming I should be healed by now when there is no cure and if anything I’ve been degenerating for 10 years etcetera that the administrator or somebody had told the lady that opens the mail at HMS a they said if any mail comes from me to throw it out in had been resolved when the only email I was sending them was paperwork for them to send to my lawyer so that I may have him represent me this happened at least for times until I finally sent it certified mail after which my advocate disappeared for 3 days and want return my calls now and I am still haven’t to pay out of pocket with money I don’t have to be in a sort of limbo without quality of life the man told me his name is Andrew Perry MD he is a pediatrician and when I explained to him about degenerative disc disease and asked if he knew about it his reply was I don’t care what you have I am only concerned about getting you off of these dangerous levels of morphine I have never been hospitalized for an overdose or have had any problems with my medication for 10-plus years my doctor is behind me and appealed twice however I am still having to pay out of pocket with money I don’t have to keep myself out of the hospital because of the withdrawals I would suffer if I were not able to get the medication I’m able to it is still not enough medication to keep me from limbo and having any quality of life do you have any suggestions for me I also have panic disorder panic attacks post-traumatic stress disorder and ADHD hyperactive and had decided to leave a mentally and physically abusive relationship right before this man was hired the last year has been a living hell how do they keep getting away with this what can I do to stop it thank you

    • Tracey Rogers says:

      Stacey, the same thing is happening to me. I’ve been on the same medications (Effexor 150mgs, temezapam 30mgs at bedtime during periods of insomnia and (2) tramadols up to 4 times a day – all of them at the same dosage) for over 10 years. I’ve had the same insurance company (Cigna) for over 10 years. They’ve had no problem paying my medical visits and medication for over 10 years. I’ve held the same job for 10 years. Same doctor, same pharmacy. I am functioning and stable due to my medications, which also allows me to sleep, work, exercise on a daily basis (treadmill, stretching, and specific PT exercises for my neck and shoulders), take care of my family, my house, my pets and most of all – I have some quality of life. If it was not for these medications, I would be in bed 24/7, crying all of the time and on the verge of suicide due to the constant pain. (This was how I was prior to the medications I’ve been on for 10 years.)

      Prior to finding my doctor who helped find the medication combo that has improved my mobility, functionality, and ability to hold a job I’ve been through physical therapy – traction, exercise, and ultrasonic massage – all three at different times for 3 months each with 3 sessions per week; 3 months of hydrotherapy – 3 sessions a week; a series of 3 epidural steroid injections in c-spine under fluoroscopy – c5/c6 – which caused even more permanent damage; 3 months of chiro sessions – 2 session a week IIRC; I’ve tried just about every type of anti-convulsant – gabapentin, lyrica, etc., every type of anti-inflammatories – OTC and prescription – Vioxx (now off the market), Celebrex, Bextra, meloxicam, Diclofenac, etc; muscle relaxers – soma, Flexeril, Skelaxin, etc; tricyclic antidepressants – amitriptyline, nortriptyline (insomnia); atypical antidepressants – Remeron, Trazedone (both for insomnia), etc.; antipsychotic – Zyprexa (insomnia); Prescription sleep medications – Lunesta, Ambien, Ambien CR; OTC sleep meds – Benadryl, Tylenol PM, Melatonin, etc.; OTC herbal meds – valerium, st. john’s wart, kava kava; acupuncture; massage; guaifenesin therapy; dextromorphan therapy (the active anti-tussive in OTC Robitussin); anti-inflammatory diet (still doing this); TENS Unit during flares (still use); splurged on a very expensive mattress (still use); installed a Jacuzzi tub (one of my best friends lol); heating pad for neck and shoulders (my other best friend lol). The medications and treatments I listed above either did not help, sedated me too much, or swelled my feet and legs 3 times their normal size.

      Recently, Cigna made the claim that they will “reduce” their customers’ opioid consumption by 25% while Aetna and BCBS has been doing this for the past couple of years in response to the opioid “epidemic” … this is how they’re doing it – by denying our pain management visits and medication claims (most likely, using the excuse that it is not the “standard of care”). Chronic pain patients who rely on prescription opioids to give you, me and others not only some quality to our lives, but also allow us to function to the best of our ability (depending on our debilitating conditions), are among the most discriminated patients in the medical field.

      From day one, we are treated like criminals – regular and random drug tests, regular and random pill counts (Hey! Who cares that we may be in another state due to a medical emergency with a parent, sibling, or other loved one?! We have 24 hours to get back and get tested or our pills counted or we’re deemed incompliant to the pages worth of “rules” we have to follow, usually dropped as patients, and many unable to find another doctor willing to risk his license to continue our long-term opioid therapy). I don’t know what we can do about this, but one thing is for sure – we chronic pain patients need to band together and start fighting back. Fight back against these ridiculous federal and state regulations, doctors getting their MD licenses stripped, losing their freedom due to the increased prosecutions of those who dare to continue using long-term opioid therapy on their patients who benefit from these medications, and fight back against these insurance companies.

      • WC SUTTER HEALTH says:

        Let me know how to fight the insurance company, 2011 I had a 2000lb door close on my neck and shoulder had multiple surgeries and then found a perfect amount of 2 drugs to help me through the daily pain.
        After I was stationary this year the insurance company stopped paying for my meds. And gave me an option take some money and close my case without meds or future medical .
        2nd option was to keep future medical and no meds.
        I’m not well without meds and have taken many painful test to show that I need them.
        Thanks ??

  • Maryland says:

    I have a question….I have health insurance through my husband job. Well when his other contract co. Lost their contract, we now have this one. Well in the start of the coverage, they sent form requesting my doctors name and info, and sign a release for my med. history. They requested all the information even from doctors BEFORE I was covered through them., which through these form never stated WHY and what where they doing with this personal info. Which I did not give them. Now they are denying bills, when I called to inquire, they stated cause they want this info. And I questioned why, I was told cause they want that’s why they are not paying the bills and will not until they receive it. I have a VERY complex health history and I believe they will be picking and choosing what they want to pay for. And with my health, I truly NEED insurance but I don’t want my person health history used against me. Help!!!!!!!!!!

  • Sean says:

    I was just recently denied ALIF surgery on my lower lumbar by BCBSNC. Reading the prior posting has taught me a lot. I am for sure going to fight this and I am looking forward to hearing back from my doctor as to the next step. The procedure requested went through three different Neurosurgeons before going to the insurance for approval. I have been in so much pain for the last eight months to where It is hard to even put on my clothes. Can’t walk for more than 20 minutes and cannot sit for more than 15-20 minutes. Painful when getting up and pain down my leg. PT doesn’t seem to work and it hurts to even exercise. I am looking for answers and help as to what needs to be done next to start an appeal. Does this begin with my doctor appealing or is this something I need to initiate.

    • Gari Phillips says:

      Hi there! I just went thru this process. Was it a procedure that was denied or something that has already been done and now they are rejecting the invoice?


      • Sean says:

        I have not been through this procedure before. The neuro surgeon that I have seen actually this request was sent up to three other surgeons and all three have concluded that this procedure was in deed necessary. I have recently spoken to my doctor and he feels that this should be appealed and he plans on bringing me into the office for spine injection and to also document that PT is not tolerable. He will then use this for ground in his appeal. My pain level now is just off the charts. I am hoping that the appeal will go through with additional documents from the doctor!!

  • Shailendra says:

    My insurance company says ” Admission was not necessary” in claim rejection.
    please help me …….

  • M says:

    First off, you have to remember, when calling the insurance company, the rep you’re talking to has no magical overruled button, regardless of your foolish and often mislead steadfast and persistent haggling. When your calling customer service, you’re not negotiating anything, and the rep you’re talking to generally wants to help and correct your issue, because that is how and why they get paid to do that. Its not fair, and its a shame when people read garbage ads like this one and think a call to the insurance is gonna change anything. Instead, follow the appeal instructions clearly listed on the explanation of benefits, and provide any supporting details you can to the appeal, so when the insurance company recieves your appeal, its processed correctly and avoids you the hassle of haggling with some rep whom cannot over the phone change the denial……wake up people, wake up!

  • Mike says:

    First off, you have to remember, when calling the insurance company, the rep you’re talking to has no magical overruled button, regardless of your foolish and often mislead steadfast and persistent haggling. When your calling customer service, you’re not negotiating anything, and the rep you’re talking to generally wants to help and correct your issue, because that is how and why they get paid to do that. Its not fair, and its a shame when people read garbage ads like this one and think a call to the insurance is gonna change anything. Instead, follow the appeal instructions clearly listed on the explanation of benefits, and provide any supporting details you can to the appeal, so when the insurance company recieves your appeal, its processed correctly and avoids you the hassle of haggling with some rep whom cannot over the phone change the denial……wake up people, wake up!

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  • Guntren Julie says:

    Need help getting insurance wellmark ppo to pay for surgery spinal scoliosis in new jersey iam a iowa resident my niece is 12 yrs old and this surgery called tethering much less invasive then a fusion and they wont pay and they want 50 thousand out of pocket

  • Valerie says:


    I have had a claim for IVF denied by my insurance. I did 2 cycles and the first one was covered with no problems. The second cycle was the same as the first and was denied. There is no cap to the number of cycles I can do. Anyone else had this problem?

  • Christopher R Ghiselin says:

    In 2011 I had a w/h door close onto my neck and shoulder have had multiple surgery per my Workmans comp ins carrier, went through much attempted rehabilitation after that.
    My doctors came up with a medication program that can let me function daily which is Gralise, low dose of Norco and Botox injections to my neck and shoulder .
    As soon as I became permanent and stationary the insurance company declined to pay for all medications and injections even though I have future medical from them.
    I struggle to get samples of Gralise and pay for Norco and chronic muscle tension and tremors in my right hand.
    My doctors and I tryed many many different approaches with medication and this combination is the only working .
    Hope there is hope for the rest of my life.
    Thank You

  • Whyllaine says:

    Good evening
    My daughter had an operstion and the mefival aid did not cover part of the anaestetic as he was adked yo tesubmit with a motivstion as to why he used mire than the normal amount. He tefusrd and says he does not need to justify ehy he knows his job. The other 2 parts mot covered ate because they isrf the incorrect icd10 codes they refuse to correct them even though the medical aid seny them the correct codes what can one legally do? Thank you. Whyllaine

  • No one should have to beg for their prescriptions…. I’m sick of these insurance companies dictating my health care needs!

  • Mary J Durant says:

    Can a toxicology report be wrong ? Or shall I say missed label for the wrong person if multiple people come in. If you know this person didn’t do drugs.

  • Kristie Condry says:

    Oh my goodness, this is going to be so useful while fighting the denial for my surgery!! Thank you so much! Fortunately my husband set up a spread sheet a long time ago just for me! We have everything focumred from the late 80’s to now in 2017!! Yea for us or should I say yea for me for being married to such a smart man!☺️❤️?‼️ Again, thank you!! There will no giving up on my part!!

  • Katrina Rigdon says:

    Well my insurance company denied my appeal for my medicine I don’t know what to do I need this medicine or I can died if left untreated from what I see they are saying I’m not sick enough to get it but I need this medicine because we are trying to avoid that from happening so what can I do thank you Katrina

  • At this moment I am ready to do my breakfast, after having my breakfast coming yet again to read other news.

  • Brian Zalenski says:

    Hello to all. About a week ago my girlfriend of 30 years old just found out that she has a extremely rare congenital heart defect (complete congenital absence of the pericardium). We live in Western PA and her Medicaid insurance has covered everything in PA but her cardiologist would like us to go the Cleveland Clinic in Ohio which Medicaid will not cover. Are there any suggestions or answers on how to go about getting Medicaid to approve such a thing? The doctors around Pittsburgh are having a hard time coming up with any conclusions due to the extreme rarity of the heart defect. Any help would be appreciated immensely. My email is Thank you!

  • Jared Spencer says:

    I have a terminal illness and had to go to the hospital due to it. This has happened many times in the past. I am being taken care of by my insurance company. While I was at the hospital they wanted a urinalysis. I asked them what for and the said the test was just for my hydration. Later come to find out that it was also for drugs and I came up positive for Illicit drugs. I am going to lose everything including my life. My medications cost over $18,000 and they pay me to live. What can I do?

  • This is great advice! and great info! I’ve recently had to switch insurances and it was easy to go through a company called Insurance Line One. I was able to find affordable health insurance for myself and my family that could cover ongoing health care costs.

  • […] Tips on what to do when your health insurance company denies your claim […]

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  • Grant B. says:

    Your information is very helpful – Thank you for writing. My issue is that I had back surgery at Mayo Clinic. My insurance said that they would not pay for one part of the surgery which they considered experimental (costing me $16,000). I am appealing (since I was in surgery, I couldn’t ask the doctor is what he was doing was considered experimental at the time). I am appealing but the problem is that my doctor is so busy that he doesnt have time to fill out the form for my insurance company. I’ve been waiting 5 months for him to write the letter. What should I do?

    • Joanna Haritos says:

      I hear that accupuncture for ADHD would not be covered by my insurance. The’ll only covered accupuncture for pain. It seems wrong that the insurance company would encourage that I give my 11-year old drugs rather than something inevasive. Can I appeal something like this on your advice?

  • Jenny says:

    Thank you so much for sharing a great information. I appreciate your time and effort in your work. Keep posting.

  • adele pace says:

    I had a very bad accident as a pedestrian walking out of a job interview I got. i was struck by and run over by a truck. I was laid up in hospital for months and can’t feel my leg at all except the arch – completely numb. Nerve damage, ripped muscles and all skin removed by the wheel of the truck leaving only bone and the need for a full circumferential skin graft from above the knee down to the foot. I was put on drugs long used in the treatment of neuropathic pain. I was and still am quite anxious driving. I was cleared to drive and had to change to another vehicle because of the limitations to my mobility. Unfortunately about 1.5 years after my accident i was driving down the freeway, a freeway I didn’t know, about 9pm, and was feeling tired. The Pain Management Consultants (2) from different entities recommended Endep, for neuropathic pain drug, as did my Psychiatrist who were all supportive of this well known drug for nerve pain On some occasions it made me tired but when I was driving down the freeway I felt myself losing my control of my vehicle and felt narcoleptic. I remember little but felt I was trying to get over to the left hand side of the freeway tot he emergency stopping lane as a place of refuge. My car insurance company is trying to reject my claim on the grounds I was taking a prescription drug which can have these effects.. I had no idea it could although some days I’m tireder than others and it’s hard to isolate why. Some days I’m sore, some days I haven’t slept (nightmares). I just don’t know exactly why but I suspected but the pain management specialist and his rival suggested I may have a “special sensitivity to some drugs” which could explain my reaction to this tablet. I had an accident at around 9-9.15pm and my insurance claim appear to be going to reject my insurance claim on my car. (damages 15K). I was given the car on a recommendation as I have limited mobility and it enables me to get in and out with my limited mobility. I also can’t drive a manual vehicle anymore as I can’t push the pedal (can’t dorsiflex). No charges were laid by Police in relation to the accident. Nobody was hurt. I crashed into a concrete block which acted as a natural boundary in the emergency lane. I find it difficult to understand that the Insurance Company could deny a claim where I was using drugs prescribed and encouraged by more than two pain management therapists encouraged me to take (Psychiatrist, etc). I still don’t know what caused the pain but I do know that I was losing control of my vehicle and desparately tried to get over to the side of the road to avoid hurting anyone. I never thought that the Insurance Company could deny me coverage for a tablet well known for treating nerve pain which I have a lot of but it looks like that is where things are heading.

  • Jim says:

    It seems funny that someone behind a desk that knows nothing about your medical history or what is going on besides the information allowable by the insurance forms to make a decision on your well being.But the government allows them to charge you premium prices while denieng coverage in most cases taking money for no service rendered would be called stealing.I suffer from some form of neck injury causing random but severe pains in my neck and head along with numbing sensation in the left side of my face Excellent blue Cross and sheild does not feel that an MRI is necessary and will not cover it .I find myself wondering what I have paid 75 $ a week for the last 14 years for and then I remembered if I didn’t the government will find me . GO FIGURE

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