When Your Health Insurance Doesn't Cover a Procedure

Patients May Have More Ways to Get Health Insurance Than They Think

Medical insurance claim form. Credit: Peter Dazeley / Getty Images

How can you make sure the treatment I need is covered by my health insurance? Know your insurance policy, understand your options and talk with your doctor.

"People make the assumption if the doctor orders it, it's going to be covered," says J.P. Wieske of the Council for Affordable Insurance, an insurance industry lobbying group.

Doctors view your condition through a medical perspective, though, not from an insurance standpoint.

Since they see patients who have a variety of insurance providers, they're often not as aware of the coverage provided by a particular company or plan as patients are—or should be.

Insurance policies are geared toward a broad population, so covered items are based on standard medical procedures for the average patient. Patients, though, have more alternatives—and more successes—in negotiating health care costs and benefits than many realize.

What to Do When When a Procedure or Test Is Not Covered

Ask about alternatives: Will a similar test or treatment that is covered by your insurance be just as effective as one that is not?

Talk with your doctor's office: Half of the 10 to 17 of patients who bargained to reduce the cost of medication, a healthcare provider's fee or hospitalization were successful, according to a 2002 Harris Interactive poll. You're usually better off talking with an office manager or social worker than the medical provider.

Success is even more likely if you speak with someone in person, rather than on the phone, and don't take no for an answer on the first round, according to the National Endowment for Financial Education.

Appeal to the insurance provider:  Ask your doctor for the medical codes of the recommended procedures, and investigate your insurance company's appeal process.

If you're turned down, your next step is to seek an independent review through your state department of insurance for which you will pay a maximum of $25. These reviews—available in most states—favor the consumer over the insurance company more than one-third of the time, according to Wieske. Sometimes an insurance company will go ahead and approve the coverage rather than go through the review process.

Investigate clinical trials: If you're a candidate for a clinical trial, its sponsors probably will cover the cost of many tests, procedures, prescriptions and doctor visits. If not, and if your insurance company defines the trial as experimental, it may not cover medical appointments and other routine care it would pay for if you weren't enrolled. Twenty-two states have laws mandating some insurance coverage for health care provided by clinical trials.

Get a second opinion: Another physician may suggest alternate treatments, or he or she may confirm the advice of your primary doctor. Many insurance providers pay for second opinions, but check with yours to see if any special procedures should be followed. Your doctor, trustworthy friends or relatives, university teaching hospitals and medical societies can provide you with names of medical professionals.

If all else fails, suggest a payment plan: If the treatment is essential and not covered by insurance, ask your doctor's office to work with you to pay the bill over a period of time.


Clinical Trials: State Laws Regarding Insurance Coverage. 12 June 2008. American Cancer Society.

"Haggling" With Health Care Providers about Their Prices Likely to Increase Sharply as Out-Of-Pocket Costs Rise. 6 March 2002. Harris Interactive. 

Health Insurance: Understanding What It Covers. December 2006. American Academy of Family Physicians. 

How to Get a Second Opinion. 10 September 2008. U.S. Department of Health and Human Services.

Top 10 Ways to Make Your Health Benefits Work for You. 2008. U.S. Department of Labor. 

Questions to Ask Your Doctor. 8 May 2007. University of California, San Francisco.

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