I did everything 'right' with my health insurance - and still got a surprise bill. Here's what I learned.

By Carly Newhouse And here's what I would do differently next time It's hard even for a healthcare insider to navigate the system, let alone appeal a denial with amorphous reasoning behind it. I've worked in healthcare for 13 years, and I still struggle with unexpected medical bills. In late 2024, my doctor recommended pelvic-floor physical therapy. Like the good student and healthcare aficionado I am, I did everything "right." I called my insurance, confirmed no prior authorization was required, got a list of in-network providers and called the outpatient clinic to confirm they accepted my plan. I did PT twice a week for 11 weeks. All was well - until I got a bill showing I somehow owed thousands of dollars for those visits. I assumed it was an error - that the clinic hadn't properly run my insurance. It wasn't: When I called my insurer, I was told that although the provider was in-network, the clinic was owned by a hospital, which meant it's billed under a more pricey hospital facility code. My plan covered hospital care at 60% until I hit my deductible. That meant I was on the hook for the outstanding 40%. Conveniently, neither my insurer nor the clinic had mentioned the site-of-care issue when I first called to verify coverage. Since the bills took 11 weeks to find my mailbox, I didn't find out until I had completed 22 sessions. With my professional experience and righteous fury in hand, I immediately appealed. Denial data for employer-sponsored and Medicare Advantage plans is scarce, but two recent data points would have raised my expectations. Research published in April found that 53% of commercial health-insurance denials in New York were overturned in 2025, up from 38% in 2019. And Affordable Care Act health-insurance plans, which face strict reporting requirements, saw a 34% reversal rate for appealed denials in 2024, according to a KFF analysis. Given the complexity and time-consuming nature of appeals, very few pursue it. According to KFF, only 1% of ACA-plan denials were appealed in 2024, up from a mere 0.2% in 2021. That is a shockingly low rate considering that these plans denied 19% of in-network claims - that's nearly 1 in 5(!) - and 37% of out-of-network claims in 2024. The most common reasons cited for denial by insurers were vague and unclear: 36% of denials were described as "other [reason not listed]" and 25% as "administrative reasons." It's hard even for a healthcare insider to navigate the system, let alone appeal a denial with amorphous reasoning behind it. That didn't stop me. My first appeal went nowhere, and the denial letter didn't cite a reason for the decision. I enlisted my husband, who is a lawyer, to draft a more detailed appeal that included exhibits from my employer health-plan documents. Same result, same lack of explanation for the denial. I'm not one to take these things sitting down, so I asked around and found a company called Sheer Health, which developed a health-insurance advocacy platform to help people with denied claims. Sign me up! Sheer Health's team let me know that it helps with claims like mine frequently since physical- and occupational-therapy claims are the most commonly denied, thanks to timed treatment units and strict medical-necessity guidelines. Months of sweat and tears had gotten me nowhere. Within a few weeks, Sheer Health's team used much of the same information from my appeal to get the denial reversed. I ended up paying no more than the copays I'd expected. (I don't have a financial relationship with Sheer Health.) Here's what the company told me to do the next time I get a denial: -- Always confirm the provider takes your specific plan, not just your insurer. Don't just ask the office, "Do you take UnitedHealthcare?" ACA plans, for example, are not the same as employer-sponsored plans; they are a narrower network product sold under the same brand name. Instead, ask the provider: "Do you accept [plan name] through the [state] health exchange?" Never rely on the insurer's online directory because it might be incorrect, and always write down the date and name of the person from the provider's office who confirmed the provider accepts your plan. -- Get the facility name and billing codes from the provider's office before your visit. Ask for the facility name; the CPT code, which describes a medical service or procedure; the ICD-10 code, which is used to track symptoms and diagnosis; and place-of-service (POS) codes, which are what the office will include on their claim submission to your insurer. Write it all down. -- Cross-check everything with your insurer. Confirm the provider and site are in-network, that no prior authorization is needed and that the POS code qualifies for in-network benefits. Ask about your specific benefit level, knowing that having to pay toward a deductible versus a copay can wildly impact what you owe. As always, write down the name of the representative, the reference number and the date of the conversation. -- Ask your insurer if prior authorization or a referral script is required before the appointment. Some plans require it before they will cover certain services (like physical therapy or imaging). -- Verify every referral separately. If your in-network provider refers you to a specialist or a physical, occupational or speech therapist, repeat the process for each newly referred provider. Sheer Health also told me to look out for two common traps: -- Outpatient clinics affiliated with hospitals often bill as hospitals. A visit at a location that looks like a standard outpatient office can be billed under a hospital facility code, turning a $25 copay into a $350 bill for the exact same service, depending on whether the POS is 11 (office) or 22 (hospital outpatient). Confirm the POS code that the site will use in advance, then verify that your insurer applies in-network benefits for said code. I learned this the hard way! -- In-network providers can use out-of-network locations. If your in-network provider performs a procedure at a facility that isn't, you'll be stuck with the bill. Always confirm both the provider and the specific location are in-network with your plan. Carly Newhouse is a licensed clinical social worker, health-tech consultant, writer and angel investor. She has held diverse strategic roles at the intersection of go-to-market, clinical and operations in digital health, currently consults for venture-capital and early-stage digital health companies, and writes for the Massively Better Healthcare blog. -Carly Newhouse This content was created by MarketWatch, which is operated by Dow Jones & Co. MarketWatch is published independently from Dow Jones Newswires and The Wall Street Journal. (END) Dow Jones Newswires 09-08-26 1255ET Copyright (c) 2026 Dow Jones & Company, Inc.