The Smart Patient's Guide to
Chronic Pain Management

7 Strategies to Help Avoid Health Insurance Claim Woes

Living with chronic pain or illness is challenging enough. No one wants the added stress of worrying about health coverage. To help navigate the insurance minefield, we asked experts what to do before a procedure or treatment to avoid a denial of services.

Recently, I had a screening colonoscopy, a procedure covered in full according to my insurance policy’s Explanation of Benefits (EOB). To verify, I called the insurer beforehand and confirmed that the doctor, facility and anesthesiologist were in-network and that I was indeed fully covered. As the screening was considered preventive care, I did not have a co-pay or deductible.

A few weeks later, to my surprise, I received a bill from the anesthesiologist for $338.65; the amount that the doctor said I owed after insurance paid its share. When I called the anesthesiologist’s office, I learned that the doctor’s billing department had submitted the bill to my insurer using the procedure code for a procedure that was not covered in full. I explained the mistake and advised her to call my doctor’s office to clear up the misunderstanding. Once the bill was resubmitted with the proper code, the insurer paid the full amount.

What happened to me was an all too common occurrence. Incorrect coding is one of the most frequent reasons for medical billing claim denials (see also Part 2 of this article on how to respond to a denial). According to a 2015 Advisory Board Benchmarking Survey, demographic and technical errors—a misspelled name, incorrect Social Security number, missing provider identification, incorrect plan identification number, or an incorrect diagnosis or procedure code—factor into 61% of initial medical billing denials.

When it comes to health insurance, avoidance is good. This means doing everything you can to make sure the care you need is covered. Below are 7 strategies that may help you guard against an insurance claim denial.

1. Read Your Policy Thoroughly

While it may be boring and arduous to decipher, every expert we spoke to agreed that the first step to avoiding unwanted denials is understanding your insurance policy’s Explanation of Benefits (EOB). The EOB you receive may be the full plan or a summary of benefits. Along with digesting what is covered, it’s equally important to pay attention to the exclusions portions of the plan that explains what is not covered. If you are unsure of the language or coverage, call the insurer and ask for a more detailed explanation.

2. Get a Handle on In-Network versus Out-of-Network Coverage

Be aware of the difference between an in-network/preferred provider and an out-of-network provider. An in-network/preferred provider has contracted with your health insurer to provide services to you at a negotiated rate. In contrast, an out-of-network provider has no contract or negotiated rate with the health plan. In- and out-of-network designation holds true for hospitals as well as outpatient and diagnostic testing facilities.

If the physician is in-network, but the hospital or facility is not, or if during a hospital stay you are seen by or treated by an out-of-network physician—an anesthesiologist, for example—you could be hit with a hefty surprise bill. Some plans do not cover or reimburse for out-of-network, non-emergency care. Others limit the payment to an amount that the insurer determines is the “usual and customary” rate for the care or procedure. When this happens, you may be billed by the out-of-network provider or hospital for the difference between what a health plan pays and what the provider charges; this practice is called “balance billing” and the “balance” could be hundreds or thousands of dollars in charges.

Although there is no federal law prohibiting balance/surprise billing, as of August 2018, about 21 states have some protections and six states—California, Connecticut, Florida, Illinois, Maryland and New York—have comprehensive consumer protection. In those six states, you cannot be balance-billed for care in an emergency department (ED) or non-emergency care in an in-network hospital. The good news: A preferred provider may not balance bill you for covered services.

Tip: Always confirm your provider’s in-network status directly with the provider or office. Don’t rely on information provided on the insurer’s website or elsewhere online, as this information may be incorrect or outdated.

3. Pursue Prior Authorization

Who’s responsible for obtaining prior or pre-authorization when necessary? It’s a toss-up. These days, most, but not all, doctors’ offices do the heavy lifting required to secure prior authorization for a patient’s treatment or testing. Your doctor/provider should be the one to call the insurance company to “confirm that a procedure will be covered in advance,” says David Holt, a licensed healthcare attorney who practices in St. Paul, Minnesota.

However, some physicians leave the task to the patient who must get the authorization and have a confirmation faxed to the doctor. Your provider should tell you upfront how the pre-authorization will be handled. If the doctor is taking care of it, request a copy of the authorization from the insurance company and/or the name of the person who authorized the procedure or device.

For extra protection, call the insurance company yourself—or ask a trusted caregiver to make the call—to confirm prior authorization and to ask for the code and a description of the procedure authorized. While some insurance companies handle preauthorization in-house, benefit management companies frequently do so as well. This is almost always true for medications not in the insurer’s drug formulary, as well as top-tier, brand name, specialty and “experimental” medications. Your insurer will direct you to the Pharmacy Benefits Management Company. Ask to speak to the clinical reviewer specifically.

Tip: With restrictions on opioid medications, chronic pain patients and their doctors are desperately seeking alternatives. Many alternative medications and treatments aren’t routinely covered. To increase your chances of getting a prior authorization request approved, gather evidence to support your cause. For example, say you’re seeking approval for an implantable device to control your fibromyalgia or nerve pain. Find out from your insurer what the guidelines for approval are and collect relevant research that shows the efficacy of the drug or device. When it comes to medication, your insurer may require you to try a series of lower-priced or less novel medications before approving the drug you need. Gather your medical history and pharmacy records to show what other medications and/or devices you’ve tried in the past and why this device or medication is necessary. Have your doctor write a letter to explain why the denial of the requested drug would pose a serious threat to your health and well-being. The more “evidence” you can provide, the better your chances are.

4. Take Notes; Take Names 

Document in detail every conversation with your health insurer, asking a close friend or caregiver to listen in on the call if helpful. Note the date and time of the call, what you discussed, and the information you were given. Ask for the first and last name of the person you are speaking with, their location, employee ID number, and a reference number for the conversation. Request their email address and direct phone number. (You won’t always be able to get this information, however)

If pain or physical limitations prevent you from taking notes, ask the representative if you can record the conversation. In general, the right to record a phone conversation without permission from the other party depends on where you live. While some states require only one parties consent to tape a conversation, this consent only applies if both parties in the conversation are physically in the same state. Eleven states have laws that require all parties being recorded to consent: California, Florida, Illinois, Maryland, Massachusetts, Michigan, Montana, New Hampshire, Oregon, Pennsylvania and Washington. See more state-by-state rules.

5. Take Advantage of a Signing Bonus

Whenever you check in for any medical treatment, be it testing (blood tests, MRI, CAT scan, etc.) or surgery, and are asked to sign a consent form, insurance document, or hospital admissions paperwork, write “in-network only,” at the top or bottom of each page. This ensures that the patient gains some protection against a surprise bill from an out-of-network physician who may be employed by an in-network facility.

In fact, a Consumer Reports online survey of 2,200 US residents with private health insurance found that one-third of all respondents reported receiving a surprise medical bill. Minnesota lawyer David Holt suggests stronger wording. On each form, write, I explicitly do not consent to any out-of-network physicians working on me or my case, he says.

Tip: Always ask for hard copies of all documents you sign, including hospital intake and consent forms.

6. Break the Code

Most of us feel as if we need a cryptographer to decipher medical bills, with their dense language and pesky number and letter codes. According to the Centers for Disease Control and Medical Billing and Coding (MB&CC), a certification organization, these codes are used to classify tests, surgeries, evaluations, and any other medical procedure performed by a healthcare provider on a patient. Before you can figure out what you’re being billed for, you need to know what the most commonly used codes represent.

Current Procedural Terminology (CPT) is a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies, and accreditation organizations. CPT codes are five digits long and may be followed by a two-digit number called a modifier. The extra digits provide the insurer with additional information to adjust their payment, such as if you had more than one x-ray in the same visit. Generally, if the code you see is seven characters long, a modifier has been added.

Healthcare Common Procedure Coding System (HCPCS) is produced by the Centers for Medicare and Medicaid Services (CMS). HCPCS codes are one letter, plus four digits that may be followed by a two-digit modifier. Understanding the intricacies of HCPCS isn’t necessary. All you need to know is that these codes identify, among other things, the medication you received along with non-physician services like ambulance rides, wheelchairs, walkers, medical equipment, and other medical services.

Medical coding errors are common. If you end up incurring a charge for a doctor visit, procedure or service that you believe and were told by your insurer would be covered, check that the information provided by the doctor, facility and any other provider is correct. Check the customary rate and codes for certain procedures here.

7. Review Your Bills Closely

Whenever you receive medical care, you’re going to get a bill. During a hospital stay or a visit to the emergency room, you’ll receive a bill from every physician or specialist who provided care. You may also get a bill from a doctor you never met—a radiologist, pathologist, or a doctor who came in to check on you while you were sleeping. Some bills may only list the total amount owed, even if you received multiple services. In that case, “Always request an itemized bill that lists every single service and item that you are being asked to pay,” says Deborah Bain, RN, managing director of Prism Health Advocates, a company that assists clients with health insurance denials and disputes. “An itemized bill makes errors easier to spot. You may find charges for care you never received, overcharges, or duplicate charges for the same service.”

If you catch any errors, call the hospital billing department and/or the individual doctors and calmly state the problem or mistake. If the hospital or provider isn’t helpful, call your health insurer and explain. Your insurer does not want to pay for a duplicate service!


Overall, try to stay calm and remember that avoiding insurance woes takes persistence and assertiveness. When dealing with your insurance company, keep your frustration in check. Venting to a representative probably won’t help your cause. Still, you have the right to be heard, have your questions answered and your concerns addressed. Maintaining your poise doesn’t prohibit you from moving up the chain of command and asking to speak to the appropriate supervisors.

Read Part 2 of this article:  What to do When Your Health Insurance Company Denies a Claim

Updated on: 04/29/19
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