What to do when your health insurance denies coverage

Summary

Life Kit Podcast Summary

Episode: What to do when your health insurance denies coverage
Host: Marielle Segarra (NPR)
Guest: Jackie Fortier (KFF Health News)
Date: September 18, 2025

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Overview

This episode of Life Kit is an essential guide to handling one of the most aggravating aspects of the American healthcare system: what to do when your health insurance denies coverage for preventive care services. Host Marielle Segarra, joined by healthcare journalist Jackie Fortier, breaks down how preventive services should be covered by law, why denials still occur, and—most importantly—how listeners can effectively appeal these decisions. The episode is filled with practical advice, step-by-step instructions, and empowering reminders that you have rights and options.

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Key Discussion Points & Insights

1. Preventive Care—What’s Supposed to Be Free

[03:05]

• Definition: Preventive care includes annual physicals, vaccines (flu, shingles), cancer screenings (mammograms, colonoscopies), well-woman exams (breast and pelvic), and more.
• Who is covered: Most health plans must cover preventive care with no out-of-pocket costs under the Affordable Care Act, but eligibility depends on age, gender, and health history.

  “Under most circumstances, recommended preventive care is supposed to be covered at no out of pocket cost under the Affordable Care Act.” — Jackie Fortier [03:08]

2. Why Coverage Gets Denied

[03:30–05:44]

• Common reasons: Coding mistakes, classification errors during visits, or outright administrative errors.
• Diagnostic turns: If a wellness visit becomes focused on a specific health problem (e.g., discussing an unusual mole), that portion may not be coded as preventive—and may result in a bill.

  “If a health issue comes up...that consult can be billed separately. So the patient could then owe like, a copayment or a deductible charge for that part of the visit.” — Jackie Fortier [04:41]

3. When You Receive a Bill—First Steps

[05:31–06:43]

• Check for errors: Confirm that the provider submitted the claim to your insurance. Sometimes, bills are sent before even doing so, or are sent to the wrong insurer.

  “The provider may not have submitted the claim to insurance or you get a rejection from insurance, but a rejection in that case...is often something you can appeal and win.” — Jackie Fortier [05:44]

• Don’t pay immediately: Even if a bill says “due upon receipt,” take the time to investigate.

4. Appealing a Denial—How To Do It

[07:02–12:08]

• Emphasize persistence: Insurance companies “count on people giving up,” but most appeals succeed.

  “Do not take the first no as the final answer. It’s really just a starting point.” — Jackie Fortier [07:02]

• Step-by-step appeal:
  1. Read the denial document for the actual reason.
  2. Contact customer service—be polite and record who you speak to and what they say.
  3. Gather key documents: Explanation of Benefits, insurance policy, medical records, doctor’s letters, and, crucially, documentation showing that the service should be federally covered as preventive.
  4. Write an appeal letter: Keep it factual and concise—emotional appeals aren’t effective.
  5. Submit correctly: Use the portal or certified mail, keep all records, and confirm receipt.
  6. Notify the provider: Inform the hospital/doctor billing office that you’re actively disputing.

  “Appeals are not about emotion. They’re about documentation.” — Jackie Fortier [12:08] “Don’t put the bill on a credit card, because then it changes it into credit card debt, and you lose a bunch of protections.” — Jackie Fortier [10:06]

5. If Your Appeal Is Denied—Next Steps

[15:20–18:11]

• External medical review: Legally required, unbiased review by a third-party health professional. Their decision is final and binding.

  “This is like the Supreme Court of Health decisions. Their decision is final...But it’s unbiased, it’s medically based, and it is legally binding for your insurance company.” — Jackie Fortier [15:51]

• How to request: Instructions buried in denial documents; state insurance departments or nonprofits can help.
• Odds of success: “72% of [California] health fund members...end up getting the service that they requested.” — Mary Watanabe, via Marielle Segarra [17:20]

6. If All Else Fails—Negotiation & Assistance

[18:34–21:42]

• Financial assistance: Nonprofit hospitals must offer it; you may qualify even if underinsured.
• Negotiate bills: Ask for discounts (“settlement amount”) or payment plans (with no interest or late fees).

  “Han[e]s said they just want to get paid. You know, if you offer cash, sometimes there’s a discount.” — Jackie Fortier [19:54]

• Employer assistance: HR might step in, especially if it’s a recurring issue. Sometimes, they’ll reimburse you or advocate for coverage changes in future plan years.

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Notable Quotes & Memorable Moments

• Validating Frustration:

  “Rage because now I have homework to do... Rage because why is our health care system like this?... If you feel rage or frustration or exhaustion or any of the above...that is understandable.” — Marielle Segarra [00:21]

• Real-world Struggles:

  “I talked to Anna Deutscher, whose baby son needs hearing tests...her insurance wouldn’t cover. She would spend her lunch breaks on the phone... It feels like the burden goes on the person who’s just trying to get health care. I don’t need to also make sure that the hospital codes it correctly.” — Jackie Fortier [07:02]

• On Writing the Appeal:

  “Keep it short, sweet, and factual.” — Jackie Fortier [12:17]

• External Review Success Rates:

  “72% of health fund members that come to us and file an independent medical review end up getting the service that they requested. Those are good odds.” — Mary Watanabe (quoted by Marielle Segarra) [17:20]

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Timestamps of Important Segments

• What counts as preventive care: [03:30]
• Why preventive care gets billed: [04:32–05:44]
• How to approach a denial: [07:02–09:47]
• How to file an appeal step-by-step: [10:48–12:31]
• What to do if your appeal is denied: [15:20]
• External medical review process and odds: [16:03–17:35]
• Negotiating bills & financial assistance: [18:34–21:42]
• Employer/HR's role: [20:17–21:42]
• Five key takeaways recap: [22:10–24:36]

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Recap — Five Practical Takeaways

[22:10–24:36]

1. Know your rights: Federal law mandates many preventive services be covered at no cost.
2. Double check billing mistakes: Many denials are simply errors—verify and appeal.
3. Use the appeal process: Compile documents, file a factual appeal, notify providers, and don’t pay immediately.
4. Go external if you lose an appeal: Request a third-party review; most succeed.
5. Seek help if you still owe: Look for financial assistance, negotiate, avoid credit cards for medical debt, and reach out to your employer’s HR.

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Tone: Supportive, practical, validating the frustration many listeners feel while encouraging them to persist and equipping them with concrete steps.

Best For: Anyone who has faced a health insurance denial, is anxious about handling medical bills, or wants to understand their patient rights under current U.S. health law related to preventive care.

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“Do not give up.” — Jackie Fortier [15:26]

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Transcript

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[Marielle Segarra]

Hey, it's Marielle. I have gotten a number of surprise medical bills in my life, more than I can count on one hand. Bills for services that I expected my insurance to cover. And every time my emotional response has been rage. Rage because now I have homework to do. Rage because now I have to dig up my insurance card and call people on the phone and wait on hold while they look into the matter. Rage because the bill says due upon receipt and it feels like the clock is ticking. Rage cause I had other plans for my lunch break. Rage because why is our health care system like this? I say all this because I want to acknowledge if you feel rage or frustration or exhaustion or any of the above when you're dealing with medical billing and insurance bureaucracy, that is understandable. And when you're ready, we have advice for you. Specifically, we have advice on what to do when you get a medical bill for something that should have been covered by your insurance as preventative care. Reporter Jackie Fortier has been covering this topic for a KFF Health News and NPR project called Healthcare Helpline. And on this episode of Life Kit, she's going to talk us through some tips so you'll know who to call, what to say and what information you need to appeal a health insurance denial like this.

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[Marielle Segarra]

So I thought preventive care was supposed to be free.

[Jackie Fortier]

Yeah, under most circumstances, recommended preventive care is supposed to be covered at no out of pocket cost under the Affordable Care Act. But rejections do still happen, and sometimes because of billing issues or coding mistakes or how a visit with the doctor is classified.

[Marielle Segarra]

Well, let's start with the basics. What's considered preventative under federal law?

[Jackie Fortier]

Yeah, it's actually a pretty long list, but here's some of the big ones. Annual physicals, vaccines, like flu, shingles, cancer screenings like mammograms, colonoscopies, and then, well, woman visits, which include breast and pelvic exams. These are all recommended by federal health agencies, and most health plans have to cover them by law. No out of pocket costs. There are specific lists of preventive care for groups of people, so you can go check those out for women, children, and teenagers, and for specific conditions like cancer or pregnancy.

[Marielle Segarra]

Yeah, and in some ways, that seems like a pretty straightforward list, but also your eligibility will vary based on your age and gender and health history. Right. So when we talk about cancer screenings, like mammograms, for instance, or colonoscopies, it might be considered preventative and covered for you, or it might not.

[Jackie Fortier]

Yeah. Depending on your age and your health history, it is best to look over the specific list of preventative care that's covered before you go in, if you can.

[Marielle Segarra]

What can turn an annual wellness visit into, you know, a problem visit or a diagnostic visit that requires payment?

[Jackie Fortier]

Yeah, so unfortunately, not all care that may be provided during a wellness visit or an annual physical counts as no cost preventive care under federal guidelines, which is really annoying. So it can be complicated and kind of open to interpretation. If a health issue comes up, like during a checkup that prompts a discussion, you know, you're talking to your doctor, like an unusual mole or heart palpitations. That consult can be billed separately. So the patient could then owe like, a copayment or a deductible charge for that part of the visit. So in that scenario, you could ask the doctor, you know, how they're gonna code this if this is still considered part of your wellness visit. Some doctors, you know, would consider it part of the wellness visit, and other ones might add on an additional charge for chatting about that.

[Marielle Segarra]

Okay, let's take a common scenario, like say I'm over 40 and I'm eligible for routine mammograms I go and do one, but then I get a bill for it. Does that mean that bill might be wrong?

[Jackie Fortier]

Yeah, if it meets the preventive guidelines and it was done by an in network provider, it should be covered 100%. No cost to you. You can be billed by accident. You know, the provider may not have submitted the claim to insurance or you get a rejection from insurance, but a rejection in that case that you outlined is often something that you can appeal and win.

[Marielle Segarra]

Yeah, the billing by accident has happened to me too many times to count. It's so annoying because you get this bill and it says due upon receipt in all caps, Right. And then you look on your insurance company website and you can see a claim was never submitted. And then you call the medical billing office and you say, like, what's the deal? Why didn't you submit this claim? And either they submitted it to the wrong insurance company and then gave up and just billed me, or they just didn't submit it and they're like, oh, that was an error. Our system just sent that out. Disregard. But I could have, in the meantime paid that bill and they wouldn't have told me. Probably.

[Jackie Fortier]

Yeah. And I mean, like you're describing, it's really annoying to have to babysit them and make sure that it's done correctly, but it can end up costing you a lot of money that you shouldn't have to pay.

[Marielle Segarra]

Okay. And if you do see that they submitted the claim, but my health insurance isn't covering it, or they're only covering part of it, what do you do from there?

[Jackie Fortier]

Yeah. So first things first. Don't panic. It looks scary. Insurance companies really count on people giving up, but in many cases, appeals do work. So a tip to remember is not to take the first no as the final answer. It's really just a starting point. It's more like, you know, we said no for now unless you speak up. So make sure to speak up. And that being said, it is hard. It is time consuming. I talked to Anna Deutscher, whose baby son needs hearing tests every few months that her insurance wouldn't cover. And she would spend her lunch breaks on the phone with the insurance company. It feels like the burden goes on the person who's just trying to get health care. I don't need to also make sure that the hospital codes it correctly and the insurance company covers it properly. And I should be worried about him, not about what other people's jobs should be to do properly.

[Marielle Segarra]

It's so upsetting.

[Jackie Fortier]

Yeah. I mean, she fought for months to get $1,200 of preventive hearing tests covered because it really strapped her family financially to pay out of pocket. So, you know, if you feel like Anna, we are here to talk about the steps to take to fight it, because you are not alone and you haven't done anything wrong.

[Marielle Segarra]

Yeah, that's a really good reminder. So, okay, I'm looking at the letter or the insurance company portal. They say this preventative service wasn't covered or was only partially covered. What do I do?

[Jackie Fortier]

So read that rejection document carefully. The insurance company has to tell you why they aren't covering the claim. And everyone who's who has had care denied has the right to appeal. So we're going to talk about what that means. When it's preventive care, you usually get an explanation of benefits. That is not a bill, but it lists the cost of your care and how much the insurance company will pay and then what you owe. So it might say something like not medically necessary or not a covered benefit. It is insurance speak. But it's important to figure out why they told you no. And then if it's not clear, call them. There's a customer service number on the back of your card. Be polite, ask questions. Write down everything who you talk to and what they said. And if you can get it in writing, that's even better.

[Marielle Segarra]

So it sounds like get the reason, not just the rejection.

[Jackie Fortier]

Yeah, exactly. You need to know why they said no in order to fight it. And then you can appeal the denial. And this is called an internal appeal because it's within the company. You don't need to be a lawyer to do it. You're just asking the insurer to reconsider their decision not to pay for a certain portion of your care. So pull up your insurance policy. It's usually called a summary plan description. It'll tell you what's covered, what's not, and then what hoops you have to jump through to appeal it.

[Marielle Segarra]

Okay. In the meantime, right, I'm dealing with the insurance company, but maybe I've also gotten a bill from the medical billing office or the hospital. What do I do with that? Like, can I call them and say, I'm still working this out with my insurance, so I'm not gonna pay y' all yet. Cause I think this should have been covered.

[Jackie Fortier]

Yes, you absolutely should call the billing department and tell them the situation. If you're in the appeals process, they can't collect from you, but you need to get that clock going. You may have up to six months, but you Know, it's best to get the ball rolling and start collecting the documents that you'll need for an appeal, which takes time. And be sure to check the denial letter for your exact deadlines. So the best thing to do is don't ignore it. Don't put the bill on a credit card, because then it changes it into credit card debt, and you lose a bunch of protections that you have with medical debt. So contact the billing office and tell them that you're appealing it.

[Marielle Segarra]

Okay. And can you walk me through the steps to do this?

[Jackie Fortier]

Yeah, totally. So a lot of the time, there's an appeal form that you'll need to fill out. It's likely on your insurer's website. If you can't find it online, look at your explanation of benefits.

[Marielle Segarra]

Okay. And what kinds of documents would I need to gather?

[Jackie Fortier]

Yeah, so this is really important. Back the appeal up with medical evidence. You'll want to write a letter explaining why you disagree with the rejection. Then include any relevant medical records or test results. And if it's a service that's supposed to be preventive, include a copy of the federal regulations that say so. And if you can get a letter from your doctor, this can be a big help. Something along the lines of, this treatment is medically necessary and preventive for this patient, you know, because. And then their medical reasoning from the doctor. That kind of support really does carry weight within the appeals process. So let's say your insurance denied coverage for a mental health screening, which is something that should be covered. Your appeal letter might say, I'm appealing the claim rejection related to mental health screening. On April 1, the insurance company stated it was not preventive, but in this supporting document, it's listed as a preventive service. Enclosed is a letter from my doctor, Dr. Smith, who explained why it's medically necessary. So think of it like making a case in court. Appeals are not about emotion. They're about documentation.

[Marielle Segarra]

Okay, so I shouldn't include in the letter how this has affected me financially or how mad I am about their mishandling of this?

[Jackie Fortier]

Yeah. Unfortunately, that won't help your case. It might feel cathartic, but you want to make it, you know, short, sweet, and factual.

[Marielle Segarra]

All right, so you gather those documents, you write your letter, then you just hit submit and see what happens?

[Jackie Fortier]

Not quite. You want to make sure that they actually receive it. So either upload it to that portal, they usually have one online, or you can send it via certified mail. Some people feel more comfortable that way. And that way, you have proof that it was delivered. And then of course, keep copies of everything, you know, for your own records. Make sure to keep an eye on your credit report and make sure that that bill isn't showing up as an unpaid or delinquent or anything like that. And then, you know, in some cases they might say to your appeal, you know what, we screwed up our bad. We should have covered you. So make sure that you get that in writing that they have decided to cover you. And then keep an eye on your credit report and hang on to that confirmation in writing for about a year. Okay?

[Marielle Segarra]

This is all so annoying. It's so annoying, Jackie. Like you just went to the doctor. You had to take time off of work to go to the doctor. You know, you had to call up and sit on the phone to make the appointment and listen to the hold music. You had to go in and get prodded when you get a pap smear or when you get your blood taken. And then on top of it, you have to do this.

[Jackie Fortier]

It shouldn't be this way. And I mean, a lot of people, people have lives, right? So you could be like Anna, who I was talking about earlier, who needs those hearing tests for her son that should have been covered. I mean, you know, she was getting over giving birth, going back to work, working her full time job, having a newborn, and then gets this diagnosis that he needs these intermittent hearing tests. She has all this on top of then, you know, on her lunch hours, fighting with the insurance company in order to pay for it. It's awful.

[Marielle Segarra]

Coming up, we'll talk about your options if the insurance company denies your appeal, you do have options. That's after the break.

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[Marielle Segarra]

Okay, we're back with Life Kit. Jackie, what if the insurance company says no to your appeal?

[Jackie Fortier]

You still have options. Some people win on the second try. If they say no again, do not give up. Okay, so our next tip is you can request an external medical review. This is when an independent health professional takes a look at your case and they decide whether your health plan should cover it. This is like the Supreme Court of Health decisions. Their decision is final and you cannot appeal it.

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But.

[Jackie Fortier]

But it's unbiased, it's medically based, and it is legally binding for your insurance company.

[Marielle Segarra]

Okay, so it's like a neutral third party that could say, hey, this person actually does need that care.

[Jackie Fortier]

Yeah. And the best part is you don't have to figure it out alone. A lot of states have people that will help you through this process for free. Of course, it depends on the state you live in. Sometimes it's your state department of insurance or the Attorney General's office. There's also a lot of nonprofit consumer assistance programs, but usually, I mean, they're used to people not knowing which one to go to. So you can call, like, the AG's office and say, hey, I have this problem, and they'll direct you as to where you can go to get help.

[Marielle Segarra]

Okay. Is that where you start if you want an external medical review? Like, how do you actually request that?

[Jackie Fortier]

The insurance company has to tell you how to do it in the documents that they send you. They're required by law to tell you that you have the option to do an external medical review and the steps that you have to follow. But it's usually really buried and in this kind of legalese that can be hard to read. So I would definitely recommend that people go and get help from folks, usually at the state level. A lot of them have really good information on their website, surprisingly.

[Marielle Segarra]

How often does this work, the external medical review?

[Jackie Fortier]

Pretty often. It's surprising. I talked with Mary Watanabe, who's the head of the California Department of Managed Healthcare, and she said something that really surprised me.

[Marielle Segarra]

72% of health fund members that come to us and file an independent medical review end up getting the service that they requested. Those are good odds.

[Jackie Fortier]

Yeah. I mean, 7 in 10 people get the service paid for. I mean, that's. That's pretty great.

[Marielle Segarra]

Do you have to find the third party who does this review, or is that provided by either the insurance company or your state regulatory agency?

[Jackie Fortier]

No, it's provided by the insurance company. The external medical reviewer, the health professional can be part of, like, a third party that they have to contract and pay for. But under federal health law, they have to have an external medical review person. Sometimes there might be a little bit of a fee associated with it. Like, it's nominal, though. It's like 20 bucks.

[Marielle Segarra]

How long does the external medical review usually take?

[Jackie Fortier]

So the standard review can take up to 45 days. But if it's urgent, like, your health is at serious risk, you can request an expedited review, and that gets decided in seven days or less.

[Marielle Segarra]

What if the medical reviewer does not side with you and you don't get this service approved?

[Jackie Fortier]

Yeah. So this is kind of the point where a lot of people may feel hopeless. You've done all this work. You've filed, you know, multiple appeals. Now this independent doctor says, nope, this isn't preventive care. Insurance doesn't have to cover it. I asked Bernita Haynes, senior attorney at the National Consumer Law center, what should people do? You still have some options to either negotiate the bill with a provider or if you were uninsured at the time or underinsured at the time, depending on your state, you still may have time to apply for financial assistance for the bill. So all nonprofit hospitals, and a lot of hospitals are nonprofit, have to offer financial assistance, so you can apply for that if you don't qualify. Here's another tip. You can contact the doctor's office or the hospital billing department and ask them to lower the bill. It sounds kind of outlandish, but you can do that. Hanes said they just want to get paid. You know, if you offer cash, sometimes there's a discount. And then if they agree to that, make sure to get the negotiated amount in writing. If it's a payment plan, make sure there's no interest being charged and no late fees.

[Marielle Segarra]

We did an episode on how to lower your medical bills, and one tip we got was to ask them, what's the settlement amount? Like, how much would you take today to close this account if I gave you?

[Jackie Fortier]

It kind of feels like buying a used car.

[Marielle Segarra]

Yeah. Yeah, you can do it. Like, you don't think to try to haggle over your medical debt, but it is possible. One other thing I've been wondering about. You know, a lot of us get our health insurance through work. Can your job help at all when your insurance company says no to a service that you think should be covered?

[Jackie Fortier]

Yeah, they can. If you have insurance through your employer, get in touch with your human resources Department and let them know what's going on. Do you remember Anna Deutscher, whose son needed the hearing tests? I talked about her earlier. Yeah, that's what she did. And it worked. I also have never gone to my HR for something like this before. I didn't even know this was an option. She told HR her son would need these hearing tests for years. Her employer decided to pay Anna back for the tests she'd already paid out of pocket for. They also said they'd add hearing exams for everyone on their insurance in the next plan year, but not as preventive. That means Anna will have a copay for the next round of hearing tests. That's a little irritating because the company never said that they should have covered his hearing tests from the start as preventive. Our expert's reading of federal law was that Anna shouldn't have to pay a copay at all. But overall, Anna's happy that she won't have to pay the full cost of his hearing tests, you know, for years to come.

[Marielle Segarra]

Hmm. Yeah. I mean, I'm glad it's at least somewhat taken care of, but that is annoying. I think, though, this is a good tip. In general, if you're having an issue with your health insurance denying claims that you think should be covered whether it's a preventative service or not, go to hr. Right. Because there might be a pattern. Your coworkers maybe have experienced this too, because of some mistake on the insurance company's end.

[Jackie Fortier]

Yeah. It could help HR folks, you know, see a trend that they might want to address at the company level with the insurance company. I mean, keep in mind, your employer pays a lot of money for your health insurance, so they should want to get the services provided to their employees that, you know, they're paying for.

[Marielle Segarra]

Jackie, thank you so much for walking us through this.

[Jackie Fortier]

Yeah, thank you.

[Marielle Segarra]

That was KFF health news reporter Jackie Fortier.

[Jackie Fortier]

All right, it's time for a recap. Takeaway.

[Marielle Segarra]

One, under federal law, there's a list of preventative services that must be covered by your health insurance plan with no out of pocket costs. They include things like annual physicals, vaccines, and cancer screenings. You can find that [e-mail] Keep in mind, though, whether you're eligible for a particular test will depend on things like your age and your health history. Takeaway two, Health insurance companies do deny these services, and often that's because of an error. So if you get a bill for a service that you think should have been covered, make sure your doctor's office or hospital actually submitted a claim to your insurance first. If they did, then you find out the reason for the denial. Takeaway 3 Go to your insurance company website and file an appeal. You typically have up to 180 days to do this, and you'll need to compile some documents, including a brief letter explaining why you disagree with the denial, your medical records, a copy of the federal Preventative Health Guidelines, and a letter from your doctor stating why the care was necessary. While you wait for an answer, contact the doctor or hospital billing office and tell them you're just disputing the denial with your insurance. Do not pay the bill at this time. Takeaway 4 if your insurance company denies your appeal twice, you can ask for an external medical review, which will be done by a neutral third party. The results of that are binding and takeaway 5 if your claim is still denied, see if you qualify for financial assistance from the hospital based on your income and ask if they'll give you a discount for paying in cash. You can also set up a payment plan with the medical billing office. Don't put the debt on a credit card. You'll lose certain credit protections and have to pay a lot of interest. Do you have a question or a story about navigating the healthcare system? It could be part of an upcoming installment of Healthcare Helpline. You can share your story by following the link in the show Notes of this Episode this episode of Life Kit was produced by Sylvie Douglas. It was edited by Tanya English. Our visuals editor is Beck Harlan and our digital editor is Malika Garib. Meghan Keane is our senior supervising editor and Beth Donovan is our Executive producer. Our production team also includes Andy Taegle, Claire Marie Schneider and Margaret Serino. Engineering support comes from Stacey Abbott and Jay Siz. Fact Checking by Tyler Jones I'm Mariel Segarra. Thanks for listening.

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