“My Doctor Said the Procedure Was Covered — Then I Got a Huge Bill.” What Can You Do Next? (Attorney + Personal Guide)
Most people trust their doctor’s office when they say: “Don’t worry — this procedure is covered by your insurance.”
So did I.
I asked all the right questions, confirmed coverage with the office, and moved forward with the procedure believing I would owe nothing (or very little). Weeks later, I opened my mailbox to find exactly what you might be facing right now:
A large unexpected bill — even though the doctor’s office told me it was covered.
The frustration is real. The confusion is real. And the feeling of being blindsided is something I hear from clients every single week.
As an attorney who handles insurance claim denials — and as someone who has personally experienced this scenario — here is exactly what to do next, step-by-step.
1. Before You Panic: Understand Why the Bill Arrived
When a doctor’s office tells you a procedure is “covered,” they often mean: “Your insurance will pay something.”
Not — “You will owe nothing.”
Here’s what commonly causes these surprise bills:
✔ Insurance covered part of the procedure, but not all
This happens when:
The doctor billed multiple CPT codes — some covered, some not
Insurance allowed a smaller amount than what the doctor charged
✔ The doctor was technically out-of-network
This happens even when the office believes they are in-network.
✔ Coding or billing errors
Common ones:
Diagnosis and CPT code mismatch (CO-167)
Wrong modifier
Incorrect place of service
Procedure miscoded as non-covered
✔ The doctor’s office misunderstood your benefits
Offices often say “covered” based on:
Quick eligibility checks
Outdated insurer portals
Misinterpreting your deductible or coinsurance
Important: Just because they told you it was covered does not mean it was but you still don’t have to accept the bill.
2. Ask the Doctor’s Office for an “Itemized Bill” and “Claim Breakdown”
Call the billing office and request:
Itemized bill (with CPT and diagnosis codes)
Explanation of Benefits (EOB)
Internal notes showing the office’s coverage verification
You need to know exactly:
What they billed
What insurance paid
Which codes were denied
Why the balance is being pushed to you
This is the evidence you’ll need for either:
A patient appeal
A billing correction
A dispute of the charge
3. Compare the Bill to Your Insurance EOB
Look for these red flags:
❌ “Provider billed above allowed amount.”
You should only owe based on the allowed amount for in-network care.
❌ “Procedure not medically necessary.”
This is appealable.
❌ “Diagnosis does not support procedure.”
This is often a coding error.
❌ “Deductible/coinsurance applied incorrectly.”
Billing offices frequently misunderstand deductible rules.
If anything looks off — you have grounds to dispute or appeal.
4. Call Your Insurance Company and Ask These Exact Questions
Use this script:
“Can you walk me through each CPT code and explain (1) what was allowed, (2) what was denied, (3) the reason code, and (4) what my responsibility actually is?”
Get answers to:
Was the provider truly in-network?
Was any code billed incorrectly?
Was the denial due to medical necessity?
Was the denial due to lack of documentation?
Write down:
Date
Name of the representative
Call reference number
5. If the Office Misquoted Coverage, You Can Request a “Good Faith Adjustment”
Billing offices make mistakes — a lot of them.
If the office told you the procedure was covered, you can say:
“I underwent this procedure because your staff confirmed it was fully covered. Based on that representation, I’m requesting a good faith adjustment or reduction of the balance.”
Many offices:
Reduce the bill
Write off part of the balance
Offer hardship or courtesy adjustments
This works best when:
You confirmed coverage in writing
Or they admitted a verification error
6. If Codes Were Incorrect — Request a Corrected Claim
This step resolves THOUSANDS of dollars in wrongful bills.
Tell the office:
“Can you review the codes? Insurance told me CPT ___ was not covered because of ___. Please submit a corrected claim.”
Examples of mistakes:
Wrong diagnosis for the procedure
Missing modifier (common for imaging and surgery)
Wrong place-of-service code
Bundled/unbundled codes
A corrected claim often eliminates the bill entirely.
7. If Insurance Wrongly Denied Part of the Claim — Appeal It
This is where my experience as an attorney — and my templates — become valuable.
Most patients think appeals are only for full denials.
They’re not.
You can appeal:
Partial denials
Downcoding
Medical necessity denials
Wrong allowed amounts
Misapplied deductibles
Claims denied “in part”
This is also where your personal experience fits naturally:
I went through this myself. Insurance paid part of my claim but denied the rest due to a diagnosis mismatch. The denial was wrong. I appealed the partial denial using the same methodology I teach my clients — by submitting the correct codes, the proper medical argument, and the insurer’s own policy language.
The denial was overturned.
And that’s why I created the templates on AppealTemplates.com — because most patients don’t know how to structure an appeal that insurers take seriously.
8. When to Use One of My Appeal Templates
You should use a template when:
A code like CO-167, CO-50 (not medically necessary), CO-18(duplicate claim/service), or PR-1 appears
Your claim is denied due to out-of-network, policy exclusion (not covered by policy), lack of prior authorization, experimental or investigational treatment
A diagnosis or procedure mismatch created the bill
The insurer misapplied your deductible
Part of the claim was approved but a portion was denied
The EOB doesn’t match what the doctor told you
You feel like you’re getting the runaround
How My Templates Help
Attorney-drafted arguments
Correct structure insurers expect
Exact policy language to cite
Step-by-step evidence checklist
A section for your doctor to add supportive notes
A complete appeal ready to submit
Customizable for your specific situation
You shouldn’t have to guess — the template does the heavy lifting for you.
9. Don’t Pay Until You Understand the Bill Fully
Patients often pay simply because they feel pressured.
Don’t.
You have the right to:
Request verification notes
Request an itemized bill
Dispute inaccurate charges
Appeal insurer denials
Request a corrected claim
Request financial adjustments
Your balance may be significantly lower — or zero — once the errors are corrected.
You Are Not Alone — And You Can Fight This
Unexpected medical bills happen to millions of people each year, even when providers say procedures are covered. But with the right steps — and the right appeal structure — you can correct the errors, dispute the charges, and potentially eliminate the bill.
