I don’t think there is any special legal leverage. You have the right to ask what codes your insurance covers, and what codes providers bill under. The problem is: the person on the phone genuinely might not know. For the provider, the billing department will be able to look up codes but won’t know what the doctor is actually going to diagnose/prescribe; the doctor won’t know either, until they examine you, and they may also have different code billing options to choose from after they see you. Also, the doctor won’t speak with you on the phone (no chance in heck) because they’re busy seeing patients.

So the people you CAN get hold of on the phone genuinely may not know the answer because the caregiving side vs. the billing side don’t really coordinate. So, the first trap is: you may get incorrect codes on the phone vs. what is actually prescribed on the day of treatment. To make things worse, even if they can tell you the codes accurately, they won’t know if your insurance covers it – you have to call your insurance company for that.

So, I don’t think providers or insurance will withhold the info, but they simply might not know the right answer until they examine you, or they may give you bad info because the answer isn’t clear cut.

My best advice is: call numerous times – you may have to do a couple round trips between reception vs. billing to get to a reasonably confident answer. (Again, they won’t let you talk to a doctor.) Once you have a reasonably confident answer re: the codes, follow up with an email to confirm it in writing. Then call your insurance company to verify whether the codes are covered. Once you get an answer from them about whether the codes are covered, follow up with an email to confirm it in writing. Finally, on the day of treatment, make sure to ask the doctor to ask you first before doing any action that will result in them punching in a code that conflicts with your email-confirmed list.

TBH even being that obsessive/paranoid may not be 100% foolproof, but it should catch most potential bad surprises. It’s sad that the patient has to be the vigilante on this, but that’s unfortunately the reality of our healthcare system.

The codes should be on your bill. If they are not, call the provider’s billing department to get the codes. Then call your insurance company to ask them why those codes were not covered as you expected.

I am an immigrant and the american healthcare system is indeed crazy complicated for me.
Thank you very much for your post. Many things are much clearer for me.

I have a question regarding to this. I had a wellness visit recently and got a surprise bill. I called to my healthcare provider and they said than the tests they ran are supposed to be covered and I probably need to call to my insurance company to find out which codes had to be used so the procedures would be covered. Could you give an advise what can I do in this situation?