Why Isn’t the Insurance Paying for My Medical Bills?
Dealing with medical bills after receiving treatment can be stressful—especially when your insurance company unexpectedly denies payment or covers only part of the charges. Many patients are left wondering why their health insurance plan isn’t paying what they thought it would. Whether it’s due to seeing an out of network provider, missing documentation, or a billing issue, understanding the most common reasons for claim denials can help you resolve the problem and avoid unexpected medical bills in the future.
Common Reasons Insurance Denies Medical Bills
1. You Used an Out-of-Network Provider
One of the most common reasons insurance won’t pay is that the healthcare provider you visited was out of network. Most insurance plans have a defined health plan’s network—a list of doctors, hospitals, and clinics they have agreements with. Services from an out of network provider may not be covered at all, or only a small portion may be reimbursed.
This can happen even in emergency situations, although federal laws like the No Surprises Act may offer some protection in those cases. Always confirm whether your provider is in network before scheduling treatment, especially for non emergency care.
2. The Claim Was Filed Incorrectly
Sometimes, claims are denied due to errors in billing or missing information. This might include an incorrect policy number, a mismatch in your personal information, or the medical provider using the wrong treatment codes.
In such cases, your insurer may delay or deny payment until the claim is corrected and resubmitted. You may need to contact both the provider’s medical office and your insurance company to resolve the issue.
3. The Service Was Not Deemed Medically Necessary
Insurance companies often evaluate whether a procedure or treatment meets their criteria for medical necessity. If they decide it wasn’t essential to your care—or believe there were more affordable alternatives—they may deny coverage.
If you believe the service was justified, your healthcare provider can help support an appeals process by submitting documentation that explains why the treatment was appropriate and necessary.
4. You Haven’t Met Your Deductible
Another common reason is that you simply haven’t met your deductible. Many health insurance plans require you to pay a certain amount out-of-pocket before coverage kicks in. Until then, you may be responsible for paying the full cost of medical care, even if the provider is in network.
Review your policy carefully to understand your deductible, co-pay, and benefits to see what your responsibilities are.
5. Preauthorization Was Not Obtained
Certain procedures require preauthorization or prior approval from your insurer before they are performed. If your provider failed to get this authorization, the insurance company may refuse to pay, even if the treatment itself is covered.
Always confirm with your provider and insurer whether a particular service requires prior approval.
Steps to Take When Your Insurance Doesn’t Pay
Review the Explanation of Benefits (EOB)
Start by reviewing your Explanation of Benefits. This document outlines what was billed, what the insurance covered, and what you’re being asked to pay. Look for codes or notes that explain why the claim was denied or only partially paid.
Call the Insurance Company
Use the customer service number on the back of your insurance card. Have your reference number, policy details, and billing statements ready. Ask for a clear explanation of the denial and what steps, if any, can be taken to reverse it.
Contact the Provider’s Billing Office
Sometimes the issue lies with the provider. The billing department can confirm if the correct codes were used and whether additional documentation is needed. They can also refile the claim or provide you with corrected paperwork to submit yourself.
File an Appeal
If you disagree with the denial, you have the right to appeal the decision. This can involve:
- Requesting a formal appeal from the insurance company
- Asking your healthcare provider to submit a letter of medical necessity
- Including medical records, prescriptions, or other evidence to support your case
Under most state insurance departments, insurers are required to provide a clear timeline and process for appeals.
Seek Help if Needed
If you’re unable to resolve the issue, you can contact:
- Your state insurance commissioner
- A patient advocacy organization
- Legal aid or a healthcare attorney
In some cases, persistent billing problems may warrant further assistance to ensure your rights are protected and your care is covered appropriately.
Learn more about resolving insurance issues related to medical bills. Call Greenstein & Pittari, LLP at (800) 842-8462 to schedule your free, no-obligation consultation. You can also reach us anytime through our contact page. Let us help you take the first step toward financial recovery and peace of mind.
FAQs: Why Isn’t the Insurance Paying for My Medical Bills?
Q1: What should I do if my insurance claim was denied?
Start by reading the explanation of benefits, call your insurer to ask why the claim was denied, and contact your provider to verify the billing. If needed, you can file a formal appeal.
Q2: Can insurance refuse to pay for out-of-network services?
Yes. If the provider is not part of your health plan’s network, the insurance company may pay a reduced amount or nothing at all, unless it was emergency care.
Q3: What is the No Surprises Act?
This federal law protects patients from unexpected bills for emergency services and certain out-of-network care, particularly at in-network hospitals.
Q4: How can I find out if a provider is in-network?
Check your insurer’s online directory, or call them directly. Also, ask the provider’s office to confirm network participation before receiving treatment.
Q5: Can I dispute a medical bill if I was misled about coverage?
Yes. If you received incorrect information from your provider or insurer, you may be able to dispute the charges through your insurance company or with assistance from your state’s insurance department.