How To Get Your Health Insurance Provider To Pay For What's Not Covered

NEW YORK (MainStreet) — After Rose Aakkre experience several months of severe hemorrhaging, her doctor diagnosed her with a fibroid tumor and recommended a hysterectomy. Aakre's health insurance denied her request for surgery. Her situation was resolved by her insurance representative after she explained that the surgery was medically necessary.

You may not be able to get your insurance company to cover procedures, medicines, and the like that are explicitly not covered, but you may be able, like Aakre, to get your health insurer to cover things that are not explicitly excluded from your coverage.

"Generally speaking, unless explicitly excluded from coverage, most standard medical procedures are covered based on the criteria of medical necessity," says Kristen Stoll, a consumer health insurance expert at eHealthInsurance.com, where Aakre got her insurance. "There are certain procedures, however, when you or your doctor will need to demonstrate medical necessity before the insurer will agree to pay. These may include things like in-patient surgeries, weight-loss procedures, [and] prescription drugs not on your formulary," she says.

Typically, doctors' office staff check for coverage. However, that doesn't always work.

"We had someone come to us after she had received a colonoscopy," said Sarah O'Leary, founder of ExHale Health, a healthcare management company that helps individuals negotiate down medical bills. "She went through all of the approvals, she thought, and read her policy that said she was covered for the screening. The doctor chose to do [the colonoscopy] in a hospital."

According to O'Leary, the insurance company didn't cover the cost associated with performing the procedure in a hospital. The anesthesiologist was also out of network, despite that the procedure was performed in an in-network hospital. In addition, the type of anesthesia the doctor used was not covered by the patient's insurance.

O'Leary helped get a lot of the charges waived. But if the patient had known that she could have avoided uncovered charges by having the colonoscopy done in her doctor's office and ensuring that the anesthesiologist was in-network, "she could have avoided all of the additional charges," O'Leary says.

This underscores an important point: "If your doctor has ordered care for you which is specifically excluded from coverage under your health insurance plan, this does not mean that it will be covered," says Stoll.

"You can apply for pre-authorization of a specifically excluded service, but it is very unlikely that it will be covered," except, possibly, if you're enrolled in a self-funded group health insurance plan, says Stoll. In that case, "you may have another level of appeal beyond the health insurance company," she says.

In rare cases, an employee may get an employer-based, self-funded health plan to pay for a procedure that has been explicitly excluded from coverage under the policy, Stoll says.

Experts advise going in with the codes to ensure coverage and making sure you – and the doctor -- have the correct codes to begin with.

"Everything is billed on 'codes' -- a code for a diagnosis, a code for a procedure," says Rebecca S. Busch, CEO of Medical Business Associates. "The reason why consumers have road blocks is because all decisions and denials are based on these codes," she says.

"If you do not have the 'codes,' you are operating in the dark," Busch says.

--Written for MainStreet by S.Z. Berg, author of College on the Cheap

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