Life Kit - What to do when your health insurance denies coverage

Episode Date: September 18, 2025

What happens when you get a medical bill for something your insurance should have covered? KFF Health News reporter Jackie Fortier outlines who talk to, what to say and how to appeal a denial from your insurance company.Have a question about navigating the health care system? Contact us here and you might be part of an upcoming episode of Health Care Helpline. Follow us on Instagram: @nprlifekitSign up for our newsletter here.Have an episode idea or feedback you want to share? Email us at [e-mail] the show and listen to it sponsor-free by signing up for Life Kit+ at plus.npr.org/lifekitLearn more about sponsor message choices: podcastchoices.com/adchoicesNPR Privacy Policy

This message comes from the podcast Landlines with Allison Williams. The girls and get-out actress and her lifelong best friends, an early childhood educator and behavioral therapist, invite you to join the group chat every new parent needs. Listen wherever you get your podcasts. You're listening to Life Kit from NPR. Hey, it's Mariel. I have gotten a number of surprise medical bills in my life, more than I can count on one hand. bills for services that I expected my insurance to cover and every time my emotional response has been rage

rage because now I have homework to do rage because now I have to dig up my insurance card and call people on the phone and wait on hold while they look into the matter rage because the bill says due upon receipt and it feels like the clock is ticking rage because I had other plans for my lunch break rage because why is our health care system like this? I say all this because I want to acknowledge if you feel rage or frustration

or exhaustion or any of the above when you're dealing with medical billing and insurance bureaucracy, that is understandable. And when you're ready, we have advice for you. Specifically, we have advice on what to do when you get a medical bill for something that should have been covered by your insurance as preventative care. Reporter Jackie Fortier has been covering this topic for a KFF Health News and NPR project called Healthcare Helpline. And on this episode of Life Kit, she's going to talk us through some tips so you'll know who to call, what to say, and what information you need to appeal a health insurance denial like this.

So I thought preventative care was supposed to be free. Yeah, under most circumstances, recommended preventive care is supposed to be covered at no out-of-pocket cost under the Affordable Care Act, but rejections do still happen. And sometimes because of billing issues or coding mistakes or how a visit with the doctor is classified. Well, let's start with the basics. What's considered preventative under federal law? Yeah, it's actually a pretty long list. But here are some of the big ones, annual physicals, vaccines, like flu, shingles, cancer screenings, like mammograms, colonoscopies, and then well-woman visits. which include breast and pelvic exams. These are all recommended by federal health agencies,

and most health plans have to cover them by law, no out-of-pocket costs. There are specific lists of preventive care for groups of people. So you can go check those out for women, children, and teenagers, and for specific conditions like cancer or pregnancy. Yeah. And in some ways, that seems like a pretty straightforward list, but also your eligibility will vary based on your age and gender. and health history, right? So when we talk about cancer screenings, like mammograms, for instance, or colonoscopies, it might be considered preventative and covered for you or it might not.

Yeah, depending on your age and your health history. It is best to look over the specific list of preventative care that's covered before you go in if you can. What can turn an annual wellness visit into, you know, a problem visit or a diagnostic visit that requires payment? Yeah. So unfortunately, not all care that may be provided during a wellness visit or an annual physical counts as no-cost preventive care under federal guidelines, which is really annoying. So it can be complicated and kind of open to interpretation. If a health issue comes up like during a checkup that prompts a discussion, you know, you're talking to your doctor, like an unusual mole or heart palpitations, that consult can be billed separately. So the patient could then owe like a co-payment or a deductible charge for that part of the visit. So in that scenario, you could ask the doctor, you know, how they're going to code this if this is still considered part of your wellness visit. Some doctors, you know, would consider it part of the wellness visit and other ones might add on an additional charge for chatting about that. Okay, let's take a common scenario. Like, say I'm over 40 and I'm eligible for routine mammograms.

I go and do one, but then I get a bill for it. Does that mean that bill might be wrong? Yeah. If it meets the preventive guidelines and it was done by an in-network provider, it should be covered 100% no cost to you. You can be billed by accident. You know, the provider may not have submitted the claim to insurance or you get a rejection from insurance. But a rejection in that case that you outlined is often something that you can appeal and win. Yeah, the billing by accident has happened to me. Too many times to count. It's so annoying because you get this bill and it says, do upon receipt in all caps, right? And then you look on your insurance company website and you can see a claim was never submitted. And then you call the medical billing office and you say, like, what's the deal? Why didn't you submit this claim? And either they submitted it to the wrong insurance company and then gave up and just billed me or they just didn't submit it and they're like, oh, that was an error. Our system just sent that out. Disregard. But I could have, in the meantime, paid that bill, and they wouldn't have told me probably.

Yeah. And I mean, like you're describing, it's really annoying to have to babysit them and make sure that it's done correctly. But it can end up costing you a lot of money that you shouldn't have to pay. Okay. And if you do see that they submitted the claim, but my health insurance isn't covering it or they're only covering part of it, what do you do from there? Yeah. So first things first, don't panic. It looks scary.

Insurance companies really count on people. giving up, but in many cases, appeals do work. So a tip to remember is not to take the first no as the final answer. It's really just a starting point. It's more like, you know, we said no for now unless you speak up. So make sure to speak up. And that being said, it is hard. It is time consuming. I talked to Anna Deutsche, whose baby son needs hearing tests every few months that her insurance wouldn't cover. And she would spend her lunch breaks on the phone with the insurance company. It feels like the burden goes on the person who's just trying to get healthcare, but I don't need to also make sure that the hospital codes it correctly and the insurance company covers it

properly. And I should be worried about him, not about what other people's jobs should be to do properly. It's so upsetting. Yeah. I mean, she fought for months to get $1,200 of preventive hearing test covered because it really strapped her family financially to pay out of pocket. So, you know, if you feel like, Anna, we are here to talk about the steps to take to fight it because you are not alone and you haven't done anything wrong. Yeah, that's a really good reminder. So, okay, I'm looking at the letter or the insurance company portal. They say this preventative service wasn't covered or was only partially covered. What do I do? So read that rejection document carefully. The insurance company has to tell you why they aren't covering the claim. And everyone

who has had care denied has the right to appeal. So, we're going to talk about what that means when it's preventive care. You usually get an explanation of benefits. That is not a bill, but it lists the cost of your care and how much the insurance company will pay and then what you owe. So it might say something like not medically necessary or not a covered benefit. It is insurance speak, but it's important to figure out why they told you no. And then if it's not clear, call them. There's a customer service number on the back of your card. Be polite, ask questions, write down everything, who you talk to and what they said. And if you can get it in writing, that's even better. So it sounds like get

the reason, not just the rejection. Yeah, exactly. You need to know why they said no in order to fight it. And then you can appeal the denial. And this is called an internal appeal because it's within the company. You don't need to be a lawyer to do it. You're just asking the insurer to reconsider their decision not to pay for a certain portion of your care. So pull up your insurance policy. It's usually called a summary plan description. It'll tell you what's covered, what's not, and then what hoops you have to jump through to appeal it. Okay.

In the meantime, right, I'm dealing with the insurance company, but maybe I've also gotten a bill from the medical billing office or the hospital. What do I do with that? Like, can I call them and say, I'm still working this out with my insurance company? insurance, so I'm not going to pay y'all yet because I think this should have been covered. Yes, you absolutely should call the billing department and tell them the situation. If you're in the appeals process, they can't collect from you. But you need to get that clock going. You may have up to six months, but, you know, it's best to get the ball rolling and start

collecting the documents that you'll need for an appeal, which takes time. And be sure to check the denial letter for your exact deadlines. So the best thing to do is don't ignore it. Don't put the bill on a credit card because then it changes it into credit card debt and you lose a bunch of protections that you have with medical debt. So contact the billing office and tell them that you're appealing it. Okay. And can you walk me through the steps to do this? Yeah, totally.

So a lot of the time there's an appeal form that you'll need to fill out. It's likely on your insurer's website. If you can't find it online, look at your explanation of benefits. Okay. And what kinds of documents would I need to gather? Yeah. So this is really important. Back the appeal up with medical evidence. You want to write a letter explaining why you disagree with the rejection, then include any relevant medical records or test results. And if it's a service that's supposed to be preventive, include a copy of the federal regulations that say so. And if you can get a letter from your doctor. This can be a big help. Something along the lines of this treatment is medically necessary and preventive for this patient, you know, because and then their medical reasoning from the doctor. That kind of support really does carry weight within the appeals process. So let's say your insurance denied coverage for a mental health screening, which is something that should be covered. Your appeal letter might say, I'm appealing the claim rejection related to mental

health screening on April 1st. The insurance company stated it was not preventive, but in this supporting document, it's listed as a preventive service. Enclosed is a letter from my doctor, Dr. Smith, who explains why it's medically necessary. So think of it like making a case in court. Appeals are not about emotion. They're about documentation. Okay, so I shouldn't include in the letter how this has affected me financially or how mad I am about their mishandling of this. Yeah. Unfortunately, that won't help your case. It might feel cathartic, but you want to make it, you know, short, sweet, and factual. All right. So you gather those documents. You write your letter. then you just hit submit and see what happens?

Not quite. You want to make sure that they actually receive it. So either upload it to that portal, they usually have one online, or you can send it via certified mail. Some people feel more comfortable that way. And that way you have proof that it was delivered. And then, of course, keep copies of everything, you know, for your own records. Make sure to keep an eye on your credit report and make sure that that bill isn't showing up as an unpaid or delinquent or anything like that.

And then, you know, in some cases, they might. say to your appeal, you know what, we screwed up. Our bad, we should have covered you. So make sure that you get that in writing that they have decided to cover you and then keep an eye on your credit report and hang on to that confirmation in writing for about a year. Okay. This is all so annoying. It's so annoying, Jackie. Like, you just went to the doctor. You had to take time off of work to go to the doctor. You know, you had to call up and sit on the phone. to make the appointment and listen to the hold music. You had to go in and get prodded when you get a pap smear or when you get your blood taken.

And then on top of it, you have to do this. It shouldn't be this way. And I mean, a lot of people have lives, right? So you could be like Anna, who I was talking about earlier, who needs those hearing tests for her son that should have been covered. I mean, you know, she was getting over giving birth, going back to work, working her full-time job, having a newborn, and then gets this diagnosis that he needs these intermittent hearing tests. She has all of this on top of then, you know, on her lunch hours fighting with the insurance company in order to pay for it.

It's awful. Coming up, we'll talk about your options if the insurance company denies your appeal. You do have options. That's after the break. Okay, we're back with Life Kit. Jackie, what if the insurance company says no to your appeal? You still have options. Some people win on the second try. If they say no again, do not give up. Okay, so our next tip is you can request an external medical review. This is when an independent health professional takes a look at your case and they decide whether your health plan should cover it. This is like the Supreme Court of Health decisions. Their decision is final and you cannot appeal it. But it's unbiased. It's medically based and it is legally binding for your insurance. company. Okay. So it's like a neutral third party that could say, hey, this person actually does

need that care. Yeah. And the best part is you don't have to figure it out alone. A lot of states have people that will help you through this process for free. Of course, it depends on the state you live in. Sometimes it's your State Department of Insurance or the Attorney General's office. There's also a lot of nonprofit consumer assistance programs. But usually, I mean, they're used to people not knowing which one to go to. So you can call like the AG's office and say, hey, I have this problem and they'll direct you as to where you can go to get help. Okay, is that where you start if you want an external medical review? Like how do you actually request that? The insurance company has to tell you how to do it in the documents that they send you. They're required by

law to tell you that you have the option to do an external medical review and the steps that you have to follow. But it's usually really buried and in this kind of legalese that can be hard to read. So I would definitely recommend that people go and get help from folks, usually at the state level. A lot of them have really good information on their website, surprisingly. How often does this work, the external medical review? Pretty often. It's surprising. I talked with Mary Watanabe, who's the head of the California Department of Managed Healthcare. And she said something that really surprised me. 72% of health plan members that come to us and file an independent medical review end up getting the service that they requested.

Those are good odds. Yeah. I mean, seven and ten people get the service paid for. I mean, that's pretty great. Do you have to find the third party who does this review? Or is that provided by either the insurance company or your state regulatory agency? No, it's provided by the insurance company. The external medical reviewer, the health professional, can be part of like a third party that they have to contract and pay for. But under federal health law, they have to have an external medical review person. Sometimes there might be a little bit of a fee associated with it. Like it's nominal, though. It's like 20 bucks. How long does the external medical review usually take? So the standard review can take up to 45 days, but if it's urgent, like your health is at serious risk,

you can request an expedited review. And that gets decided in seven days or less. What if the medical reviewer does not side with you and you don't get this service approved? Yeah. So this is kind of the point where a lot of people may feel hopeless. You've done all this work. You've filed, you know, multiple appeals. Now this independent doctor says, nope, this isn't preventative. care, insurance doesn't have to cover it. I asked Bernita Haynes, senior attorney at the National Consumer Law Center, what should people do? You still have some options to either negotiate the bill with a provider, or if you are uninsured at the time or underinsured at the time, depending on your state, you still may have time to apply for financial assistance for the bill. So all nonprofit

hospitals, and a lot of hospitals are nonprofit, have to offer financial assistance, so you can apply for that. If you don't qualify, here's another tip. You can contact the doctor's office or the hospital billing department and ask them to lower the bill. It sounds kind of outlandish, but you can do that. Haynes said they just want to get paid. You know, if you offer cash, sometimes there's a discount. And then if they agree to that, make sure to get the negotiated amount in writing. If it's a payment plan, make sure there's no interest being charged and no late fees. We did an episode on. how to lower your medical bills.

And one tip we got was to ask them, what's the settlement amount? Like, how much would you take today to close this account? If I gave you half. It kind of feels like buying a used car. Yeah. Yeah, you can do it. Like, you don't think to try to haggle over your medical debt, but it is possible. One other thing I've been wondering about, you know, a lot of us get our health insurance through work.

can your job help at all when your insurance company says no to a service that you think should be covered? Yeah, they can. If you have insurance through your employer, get in touch with your human resources department and let them know what's going on. Do you remember Anna Deutcher, whose son needed the hearing tests? I talked about her earlier. Yeah. That's what she did. And it worked. I also have never gone to my HR for something like this before. I didn't even know this was an option. She told HR her son would need these hearing tests for years. Her employer decided to pay Anna back for the tests she'd already paid out of pocket for. They also said they'd add hearing exams for everyone on their insurance in the next plan year, but not as preventive. That means Anna will have a co-pay for the next round of hearing tests.

That's a little irritating because the company never said that they should have covered his hearing tests from the start as preventive. our experts reading of federal law was that Anna shouldn't have to pay a co-pay at all. But overall, Anna's happy that she won't have to pay the full cost of his hearing tests, you know, for years to come. Hmm. Yeah, I mean, I'm glad it's at least somewhat taken care of, but that is annoying. I think, though, this is a good tip in general if you're having an issue with your health insurance denying claims that you think should be covered, whether it's a preventative service or not, go to HR, right? because there might be a pattern. Your coworkers maybe have experienced this too because of some mistake on the insurance company's end. Yeah, it could help HR folks, you know, see a trend that they might want to address at the company level with the insurance company.

I mean, keep in mind, your employer pays a lot of money for your health insurance. So they should want to get the services provided to their employees that, you know, they're paying for. Jackie, thank you so much for walking us through this. Yeah, thank you. That was KFF Health News reporter Jackie 40A. All right, it's time for a recap. Takeaway one. Under federal law, there's a list of preventative services that must be covered by your health insurance plan with no out-of-pocket costs.

They include things like annual physicals, vaccines, and cancer screenings. You can find that list at health care.gov. Keep in mind, though, whether you're eligible for a particular test will depend on things like your age and your health history. Takeaway two, health insurance companies do deny these services, and often that's because of an error. So if you get a bill for a service that you think should have been covered, make sure your doctor's office or hospital actually submitted a claim to your insurance first. If they did, then you find out the reason for the denial. Takeaway three, go to your insurance company website and file an appeal. You typically have up to 180 days to do this, and you'll need to compile some documents, including a brief,

letter explaining why you disagree with a denial, your medical records, a copy of the federal preventative health guidelines, and a letter from your doctor stating why the care was necessary. While you wait for an answer, contact the doctor or hospital billing office and tell them you're disputing the denial with your insurance. Do not pay the bill at this time. Takeaway four, if your insurance company denies your appeal twice, you can ask for an external medical review, which will be done by a neutral third party. The results are, that are binding. And takeaway five, if your claim is still denied, see if you qualify for financial assistance from the hospital based on your income, and ask if they'll give you a

discount for paying in cash. You can also set up a payment plan with the medical billing office. Don't put the debt on a credit card. You'll lose certain credit protections and have to pay a lot of interest. Do you have a question or a story about navigating the health care system? It could be part of an upcoming installment of Healthcare Helpline. You can share your story by following the link in the show notes of this episode. This episode of Life Kit was produced by Sylvie Douglas. It was edited by Tanya English. Our visuals editor is Beck Harlan, and our digital editor is Malika Gereeb.

Megan Kane is our senior supervising editor, and Beth Donovan is our executive producer. Our production team also includes Andy Tagle, Claire Marie Schneider, and Margaret Serino. Engineering support comes from Stacey Abbott and Jay Sizz. Fact-checking by Tyler Jones. I'm Ariel Cigarra. Thanks for listening.