What I Learned Working on the Other Side of Insurance

Part 1: The Medical Bill That Should Have Never Arrived

One of the hardest phone calls I receive isn't from someone who had a claim denied.

It's from someone who did everything right.

Not long ago, a client called me after scheduling their first screening colonoscopy. Like many of us, they had put it off for years. Between work, family, and life, it just never seemed like the right time. Finally, they scheduled the appointment, took the day off, survived the dreaded prep, and crossed something important off their healthcare checklist.

A few weeks later, an envelope showed up in the mail.

Inside was a bill for several hundred dollars.

They called me frustrated and confused.

"I thought preventive colonoscopies were covered. Did my insurance not pay?"

It's a fair question—and one I hear more often than you might think.

The surprising part?

Many times, the problem isn't the insurance.

It's the billing.

Insurance Can Only Process What It's Given

Before I became an insurance broker, I spent years working inside the insurance industry. I worked with claims, customer service, billing, and claims management. One lesson became clear very quickly:

Insurance companies don't process claims based on what happened in the exam room.

They process claims based on the information submitted to them.

Every medical claim includes diagnosis codes and procedure codes that tell the insurance company what services were performed and why. If those codes aren't submitted correctly—or if something is missing—the claim may process differently than everyone expected.

That doesn't automatically mean someone made a mistake. Healthcare billing is incredibly complex. But it does mean that sometimes a claim deserves a second look before anyone assumes the bill is correct.

The Colonoscopy Myth

One of the biggest misconceptions I hear is this:

"If they find a polyp during my screening, it's no longer preventive, so I'll have to pay."

In many cases, that's simply not true.

If your colonoscopy was scheduled as a preventive screening, removing a polyp does not automatically change the procedure into a diagnostic colonoscopy. Preventive benefits may still apply depending on how the claim is billed and your specific health plan.

I've seen situations where a claim was corrected after the provider reviewed the coding, allowing the preventive benefits to apply just as they were intended.

That's why I always encourage people not to panic after receiving an unexpected bill.

It's Not Just Colonoscopies

The same thing can happen during your annual wellness visit.

Maybe you're there for your yearly physical and, before leaving, you mention that your shoulder has been hurting for weeks.

Many people assume that asking one extra question means the entire visit is no longer considered preventive.

That's not necessarily the case.

Often, the preventive portion of the visit remains preventive, while the additional medical concern is billed separately if appropriate. It all depends on how the visit is documented and coded.

Once again, the details matter.

Before You Pay That Bill

When an unexpected medical bill arrives, don't assume it's the final answer.

Take a few minutes to:

• Wait until you've received your Explanation of Benefits (EOB).

• Compare the EOB with the provider's bill.

• Verify that the preventive service was billed correctly.

• Contact the provider's billing office if something doesn't make sense.

• Ask questions before writing the check.

I've seen people save hundreds—and sometimes thousands—of dollars simply because they slowed down long enough to verify what happened.

Cheryl's Tip 💡

An Explanation of Benefits is not a bill.

It explains how your insurance processed the claim. Your provider's bill should match what your EOB says you owe. If the two don't match, or if something feels off, ask questions before making a payment.

Five minutes on the phone could save you hundreds of dollars.

My Final Thought

One of the reasons I love what I do is because I know how confusing insurance can feel. I've seen it from both sides.

Most people don't need to become insurance experts.

They just need someone willing to explain what happened, point them in the right direction, and help them ask the right questions.

Insurance doesn't have to be overwhelming.

Sometimes, understanding it starts with one conversation.

Until next time, stay informed and stay covered.

— Cheryl Houtz

Your Insurance Friend with Benefits