I want to dive into a topic that came up recently with one of my clients: insurance plans and different diagnoses. The complexity of insurance coverage can be frustrating, especially when you think everything is covered, only to be hit with a denial after filing a claim. Let me share a real-world example.

The Oscar Insurance Situation

A client of mine has an Oscar plan with no deductible and a $70 copay for specialists. They needed physical therapy, and their provider billed Oscar for it. To their surprise, Oscar denied the claim. The client was understandably upset and told me, “I need a plan that covers this!” But here’s the catch: not every diagnosis or procedure code is covered, even if you have a fantastic plan on paper.

Why Did This Happen?

Insurance companies operate on a system of diagnosis codes and billing codes. These are codes that correspond to specific treatments, conditions, and procedures. Sometimes, even if a service is generally covered by your insurance, the diagnosis code attached to your claim may not be eligible for coverage. This can happen for a variety of reasons, but unfortunately, neither you nor I have access to which codes are covered in advance.

The most frustrating part? You don’t know what will be covered until you actually file the claim. For anyone trying to make informed decisions about their healthcare, this can be a major roadblock. However, there are steps you can take to avoid surprises.

Pre-Authorization is Key

Many plans, like Oscar, often require pre-authorization for certain services, especially for treatments like physical therapy, MRIs, or CT scans. If you don’t get that pre-authorization ahead of time, your claim is more likely to be denied, even if the service would otherwise be covered.

This is why it’s essential to contact your insurance company—either through their care team, the customer service portal, or live chat—to confirm whether pre-authorization is needed for a specific service. It may feel like an extra step, but it’s worth it to avoid getting stuck with a big, unexpected bill.

Check with Your Provider, Too

Your provider’s office should ideally confirm your benefits and check if pre-authorization is required. However, many providers don’t take the time to do this, which can result in billing issues. Before receiving treatment, ask your provider if they’ve checked your benefits or obtained any necessary pre-authorization. If they haven’t, you may want to contact your insurance company directly and take matters into your own hands.

The Reality of Billing Codes and Coverage

Here’s another layer of frustration: sometimes, the reason your claim is denied is due to the diagnosis code attached to it. Insurance plans often cover physical therapy or other services for certain conditions (XYZ diagnosis codes), but not others (ABC diagnosis codes). This can happen even when your doctor recommends the treatment, making the situation even more confusing and frustrating.

Unfortunately, insurance companies have the power to choose which diagnoses they’ll cover for a given service, and this information isn’t always made transparent upfront. While the Affordable Care Act (ACA) mandates that all plans cover certain services like wellness visits and some lab work, the finer details (like diagnosis-specific coverage for treatments) are left to the discretion of the insurance company.

Take Control of Your Healthcare

The best way to avoid unexpected denials is to take control of what you can. Before any procedure or treatment, confirm your benefits with both the provider and your insurance company. Find out:

• If pre-authorization is required.
• If the treatment is covered under your plan’s diagnosis and billing codes.

Yes, it’s an extra step, but it’s much easier to handle this on the front end than to be shocked with a big bill after the fact.

A Message for My Generation

For those of us who grew up in a time when you just handed your insurance card to the doctor and didn’t have to worry about all these complexities, this can feel overwhelming. Back in the day, we didn’t have to think about in-network, out-of-network, or whether we needed pre-authorization for a simple MRI.

But times have changed. The layers of coverage, copays, networks, and billing codes mean we have to be more proactive about understanding our plans. Even if you had a procedure years ago without any hassle, you may now need to jump through a few hoops to get the same care covered.

Final Thoughts

The bottom line is this: don’t assume everything is covered just because you have insurance. Before anything beyond a basic doctor visit, check with your insurance company and provider to confirm what’s covered and what you might owe. It’s an extra step, but one that could save you a lot of money—and headaches—down the road.

If you need help or assistance with your coverage, feel free to give me a call.