Insurance is complicated and billing is even more complicated. While often times a doctor’s visit is straightforward and you receive care for free or with a copayment that you pay during the visit, occassionally insurance doesn’t cover all care or sends a bill mistakenly.

If you received a bill for a doctor’s office visit that you thought was covered by insurance, here are a few things to consider:

The provider’s office is not in-network

If your doctor was out-of-network, the bill you received will most likely need to be paid out of pocket. If Apex Benefit Group is your current broker, you can find more information on how to find an in-network doctor in your company’s benefits portal.

The services provided are not covered by your plan

Even if the provider’s office does accept your insurance, you still have to check to see if the services or care you are receiving are covered by your insurance. Speaking to an insurance specialist will help you understand why the care you received was not covered. If you feel that an exception should be made to your case, you can try to appeal the decision directly with the insurance company by speaking to one of their representatives.

Human Error

It is possible that either the provider’s office or the insurance company made an error processing the claim which can result in you receiving an unexpected bill. Though this isn’t your fault, if you do not want to pay the bill, it ultimately becomes your responsibility to follow through and make sure the claim is re-processed correctly. This is where contacting your insurance broker can be very helpful, as they will be able to process this claim on your behalf. Please note that this takes cooperation and patience as the insurance broker is advocating on your behalf to the provider’s office and the insurance company.

Was pre-approval required?

Sometimes a pre-approval (or referral) is required to see a specialist, and if you seek treatment from the specialist without first receiving pre-approval, the insurance company may deny the claim and make you pay for the bill. It is best practice to find out prior to receiving care what is required, including if you need a pre-approval, what is covered by your plan, and what you will have to pay out of pocket. Sometimes the insurance company will reimburse you if you receive the pre-approval post-care, and if not, you can try to appeal that decision by contacting the insurance company directly.

Medical Necessity

Many insurance plans cover medically necessary care. This means that if the insurance company believes that the services you received were not medically necessary, they may deny your claim and leave you with the bill. If this happens, you can ask your doctor to submit a “Medical Necessity” form on your behalf to the insurance company.

What if I still think it’s not my responsibility to pay the bill but the insurance company won’t reimburse me?

Above are just some of the things to consider if you receive a bill for services you thought were covered by your insurance plan, but it is not an exhaustive list.

If you are still left with the bill after trying to appeal the decisions made by the insurance company and your insurance broker is unable to asisst you further, you can negotiate your medical bills with your provider and insurance company to set up an interest-free payment plan, a discount if you pay in full, or another compromise that will help you pay your bills without being sent to the debt collectors. Ultimately, the provider’s office wants to receive the money for services already provided, so they are likely to work out an agreeable plan with you.

You can also work with a medical billing advocate if you believe there was a fraudulent or erroneous billing practice with your case. This may sound extreme, but medical billing advocates are experts at negotiating with healthcare providers on your behalf, and may be able to lessen the burden you face with billing.

No matter what route you choose, document every effort you make and remain polite with everyone that’s working with you, as most people you will be speaking to are on your side and trying to help you figure out what you owe.

If you still need assistance, please click here to contact your benefit administrators.