The solution may be as simple as a phone call or as complicated as an appeal. Either way, you can win. When you are dealing with a medical condition or disease, you want to find the best treatment without a lot of hassle from your insurer. But insurers may deny coverage for the specialist your doctor recommended or send you a bill for care you thought was covered.

One way to avoid surprises is to choose a policy during open enrollment that covers the care you’re likely to need and review the list of in-network specialists and participating hospitals which doesn’t mean you’ll never run into roadblocks. If you do, these steps can save you thousands of dollars while helping you get the care you need.

Lock in a specialist

Getting approval for care up front usually means you won’t have to fight for coverage later. But winning that sign-off can be tricky if your doctor recommends a specialist who isn’t in your insurer’s network. Some health plans don’t cover out-of-network providers at all. Others may provide limited coverage for out-of-network care but at a much higher cost, perhaps significantly doubling your deductible and boosting your co-payment or coinsurance.

Before stretching to pay for the out-of-network specialist, ask your insurance company about your options. Generally, they will try to find an in-network doctor. Contact the doctors the insurer recommends and ask about their credentials, experience and proposed course of treatment. (You might also run their names past your primary-care doctor who recommended the out-of-network specialist in the first place.) Keep track of the doctors you call and what they say. Proving that you’ve covered the bases can be helpful later if you have to make a case for out-of-network coverage.

Even if you hope to work with another doctor, it’s a good idea to visit the specialist recommended by the insurer. “If nothing else, you get a second opinion,” says Tom Bridenstine, the managed-care ombudsman for Virginia, who helps state residents with coverage questions and appeals. You could decide to work with the in-network specialist after all, or the specialist might agree to write a letter explaining that you have a condition that he or she can’t adequately treat, Bridenstine says.

That happened to Robin Mullins, 51, from Clintwood, Virginia. She had surgery and her insurer paid the claims. But she ended up with an infection and developed a hernia. The hernia surgery was complicated because of the infection, so her doctor recommended a surgeon in Greenville, South Carolina, who specialized in the procedure. “I loved the doctor in South Carolina and felt comfortable with him,” she says.

When she tried to get preapproval for the surgeon in Greenville, Robin was denied coverage. She appealed and lost. Eventually, she got a recommendation from her insurer for an in-network surgeon in Richmond but went to Tom Bridenstine for help anyway. He suggested she at least meet with the surgeon in Richmond. “He was fantastic,” she says of her decision to go with him. Robin’s advice: “Communicate with the physician and don’t be timid about asking questions.” Another piece of advice: Keep an open mind.

Search further 

If you can’t find a doctor in your network with whom you’re comfortable, have your insurer cast a wider net, says Denise Sikora, president of DL Health Claim Solutions, in Woodbridge, New Jersey.  She recently helped a client who needed a specific type of brain surgery but couldn’t find an in-network doctor in New Jersey with the experience. Sikora kept asking the insurer for more in-network candidates and finally found a specialist in Pennsylvania.

If no in-network solution exists, the insurer may consider your situation a “network adequacy gap” and cover an out-of-network provider as if he or she were in network. At one insurance company, for example, a precertification nurse researches the options and, if there are no in-network providers in the area who can supply the service you need, the insurer will authorize the coverage.

You don’t have to stand by while someone else makes this decision. Ask the insurer what information you can provide to strengthen your case. For instance, your insurer might be receptive to a statement from your primary-care doctor saying that he has studied the case and, for this condition, he believes you are justified in seeking treatment out of network.

Some people choose to go to the out-of-network specialist despite the out-of-pocket costs. In that case, try to negotiate a deal. Some plans may agree to pay a portion of the bill at the in-network rate and have the patient pay the balance. It can help to have the physician’s office call and explain that the doctor is willing to accept in-network payment and get a preapproval or you can ask the provider for a cash discount.

Review the bill

You may think that all of your care was approved, only to receive a surprise bill from the insurance company. Don’t pay it until you get the explanation of benefits to find out why your claim was denied. The doctor may have billed with the wrong tax ID, or you may have used an old insurance card. In such cases, an appeal usually isn’t necessary, says Patrick Shea, a claims specialist and director of, in Green Bay, Wisconsin. “You can get the errors reprocessed with a phone call.”

Coding mistakes can also cause problems. The provider’s office may have input the wrong code for the procedure or the diagnosis. Sometimes the doctor can resubmit it with a different diagnosis and procedure code, and the charge will be paid.

To spot mistakes from the start, get an itemized bill that breaks down each cost separately, especially for complex procedures and hospital stays. “Anytime you receive a bill from a facility, you should ask for a detailed, itemized bill to know exactly what you’re being charged for,” says Pat Palmer, CEO of Medical Billing Advocates of America, in Roanoke, Virginia. You may have been charged for services you didn’t receive, in which case you can usually fix the error with a phone call or by providing the medical records.

Investigate two fronts

Kim Jacobs of Lakeville, Minnesota, had both authori­zation issues and clerical errors. Two years ago, she underwent an outpatient procedure. She had been told by the doctor’s office that the procedure was authorized, so she was surprised to receive a bill for nearly $10,000. “The doctor’s office said they got the approval, but I didn’t think to double-check it,” says Kim. Her doctor has since written letters to the insurer explaining why the procedure was medically necessary, in hopes of overturning the denial.

In the meantime, Kim contacted Palmer and her colleagues for help. They asked the hospital for an itemized bill and successfully disputed several of the charges, bringing the bill down by nearly $4,000. Disputing errors on the bill is a good strategy for trimming down the cost while you’re undergoing the more complicated process of appealing. Kim continues to pursue her appeal with help from Palmer and her colleagues.

Win an appeal

If you decide to appeal, your case will likely go through several layers of review—first within the insurance company, then from outside doctors, and finally from the state insurance department (or through the Department of Labor, if you’re covered by an employer’s self-funded plan). Your explanation of benefits and your insurance policy should spell out the procedure and deadlines for appeals. Sometimes you can conduct the appeal via a conference call with your physician, the insurance person who made the claims decision, and your claims advocate, says Palmer.

No matter how you do it, build a strong case. You have to do the research and pull it all together. The first step, is to find out why the claim was denied. Then gather evidence and focus your appeal specifically on that reason.

If your insurer denies your appeal, you can generally file one with your state insurance department. Find your state insurance department at

The last step? Be patient. It can take several months to go through all the levels of appeal. “I usually keep the provider in the loop and ask him to keep the bill from collection while we’re working on this,” says Sikora. Keep in mind that it’s difficult to get money back once you’ve paid it. Hold out while the appeal works through the system.

Where to get help

A medical claims specialist can help you decipher your bills and appeal denials at (Alliance of Claims Assistance Professionals). Most offer a free initial meeting to review the bills and complexity of the case, after which they generally charge $75 to $120 per hour. You can meet in person, or e-mail your bills and give the specialist permission to access your insurance-claim files online.