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  • Writer's pictureElijah Ugoh

My Health Insurance Wouldn't Cover That?!

My Health Insurance Wouldn't Cover That?!
My Health Insurance Wouldn't Cover That?!

Many people often assume that if a doctor orders a test or treatment, their insurance also covers it. Unfortunately, that is not always the case. But having your medical bills covered is precisely why you enrolled with an insurance company.

The reality is that unless you take your time to understand your health insurance coverage, you may be getting a surprise sooner or later as to what your health insurance cannot cover. Insurance can be challenging to understand, and medical billing can be even more complicated. The hard reality is that, in many cases, your insurance doesn’t cover everything.

So, what happens when your insurance wouldn’t cover your medical bills? This post explains the critical things you need to know about health insurance claims to avoid being told that your health insurance wouldn’t cover a service you need, as well as the following steps to take if you discover your health insurance won’t pay for a medical service.

Health Insurance and Paying for My Medical Services: How Do They Work?

While healthcare providers view your condition from a medical perspective, the majority of insurance companies are more concerned about their liability burden and maintaining a decent profit margin.

Thanks to health insurance policies, a broad range of health services are accessible to patients, though the costs differ depending on your health plan. Insurance policies typically aim to provide standard medical services to the average patient. Patients have the power to negotiate what they pay for health care and the benefits they get in return.

Your health insurance plan will typically cover certain healthcare services and treatments if you have a managed care plan. You will also see how much the insurance will pay for each service and how much you’re expected to pay. Your plan will also contain which healthcare providers and facilities are in-network. You have the right to know these things.

If you visit an in-network healthcare provider for a medical service and accept your insurance, they’ll file a claim on your behalf after rendering the service. Your insurance carrier will usually pay a set rate to the provider regardless of how much the provider lists in their claim.

But if your provider is in-network with your insurance plan, they’ll zero out the balance. Otherwise, you’ll have to settle the balance out of pocket. In such a scenario, you will be told that your health insurance wouldn’t cover your medical bill. In other cases, your claim may be denied altogether, and the entire cost will be billed to you.

What Does Health Insurance Not Cover?

To understand what your health insurance covers, you must ask questions and get adequate clarification before visiting your healthcare provider. But generally, most insurance companies do not cover certain medical services unless you have a special arrangement with them.

A few things that many insurance companies do not cover are:

  • Healthcare costs you incurred doing an illegal activity.

  • Cosmetic procedures, such as plastic surgery and some other dermatological procedures

  • Off-label prescriptions, although doctors may occasionally make a case for the coverage of off-label prescriptions.

  • Nursing home care. Neither Medicare nor private health insurance carriers pay for long-term care.

  • New technology in healthcare products or services. These may be accepted in the future.

  • Incorrect hospital admission status

  • Travel vaccinations

  • Fertility treatments

  • Medical services not listed on your insurance plan without pre-approvals/referrals

  • Using a healthcare provider that is not in-network

What Can I Do When My Health Insurance Wouldn’t Cover My Medical Needs?

Speak With Your Healthcare Provider: Since you may have to pay out of pocket to cover some or all of your bill, you may as well find out from the provider’s management (not the doctor) if you’re eligible for a discount. Speaking with someone in person is often more effective than phone calls or emails.

Explore Available Alternatives: Get a second opinion from other in-network healthcare providers. Alternatively, you can find out from your doctor and your insurance carrier if an alternative test or treatment is covered and is just as effective as the one initially recommended.

Appeal the Denial: You may just need to stand your ground when your insurance provider refuses to cover certain medical services and appeal to the company. Health care reforms protect consumers’ interests, such as the No Surprises Act and Affordable Care Act. Be sure to ask your provider for the recommended services' medical codes and investigate your insurance company's appeal process.

Investigate Clinical Trials: The sponsors of clinical trials may cover the cost of many tests, procedures, prescriptions, etc. If you're a clinical trial candidate, your insurance company may refuse to cover the clinical trial. Still, the Affordable Care Act does not allow insurers to deny all coverage while a patient participates in a clinical trial. They are obligated to cover in-network routine care (non-experimental care).

Contact Your State's Insurance Office. Your state’s insurance commissioner should be able to provide further clarifications, as they are in charge of regulating your health plan if it is not self-insured. Your state’s insurance department can help you clarify whether your health plan violates any specific rules.

Negotiate a Payment Plan: If all the above steps do not get the insurance company to cover some or part of the bill, you may need to discuss a suitable payment plan with the healthcare provider. This will allow you to comfortably pay the bill over a period of time.

Switch Your Health Insurance Plan: Before signing up for any health insurance plan, you want to ensure that your healthcare needs are adequately covered to avoid surprises. You can also switch your plan if you need coverage to suit your needs better. You have the option of Marketplace/Obamacare plan, Medicaid, COBRA, or Medicare.

Getting the Most Comprehensive Individual/Group Health Benefits

One efficient way to avoid the hassles of shopping for the best health coverage and minimizing your cost is by partnering with an industry-experienced broker. At Quantum Benefits, we help you navigate the entire process, and we provide you with objective healthcare solutions to choose from.

Need help selecting or renewing your health plan but not sure you’re making the best choice? Give us a call today at 203-946-0320 or fill out our contact form to speak with a representative.

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