5 Surprising Things Health Insurance May Not Cover

When it comes to health insurance, it is important to keep in mind that some injuries and other healthcare services are not covered by health insurance. Keeping these in mind is a great way to prevent the nasty surprise of a big medical bill that you thought your health insurance was going to cover. Read on to learn what to watch out for, and if you run a medical facility and are looking for professional pre-authorization services, give us a call at AuthNet today for a free demo of our state-of-the-art solution.

1. Breaking the Law

While this one may be common sense to some, others forget that your health insurance likely will not pay for healthcare costs you racked up while doing something illegal. This is called the illegal act exclusion, and if your health insurance policy has one, it means that you will not be covered if you need medical attention due to an illegal act.

A great example of this would be if you burned yourself. If you did this lighting up the grill at a family picnic and racked up a $2,000 medical bill, you are most likely going to be covered. But, if you burn yourself while freebasing cocaine and rack up a $2,000 medical bill, that bill will be coming to you if your health insurance policy has an illegal act exclusion.

2. Travel Vaccinations

If you are getting shots before a foreign vacation, there is a chance that your health insurance won’t cover it. While all non-grandfathered health insurance policies cover vaccines that are routinely recommended for preventative care within the United States, vaccinations for tropical diseases that aren’t a problem where you live are likely not covered by your health insurance plan.

3. Some Pre-Authorizations

When you are needing an MRI, CT scan, or any other expensive procedure and need a pre-authorization from your health insurance company, it doesn’t mean that it will be approved. Many health insurance providers require pre-authorization before having some procedures or tests as they want to make sure that they are absolutely necessary for the patient, but pre-authorization does not mean that it will get approved and the bill will be covered. While in most cases, pre-authorized services will end up being covered by your health insurance, it is important to keep in mind that it is not a guarantee of coverage.

4. Incorrect Hospital Admission Status

When you are admitted to the hospital, you are assigned one of two statuses: inpatient or observation. If you were admitted as an inpatient but your insurance company thinks you should have been in observation status, they might not pay for your hospital stay.

5. Nursing Home Care

Believe it or not, neither Medicare nor private health insurance companies pay for long-term nursing home care. If you don’t have long-term care insurance or qualify for Medicaid coverage (and the majority of nursing home residents do), you’ll have to pay for your nursing home yourself. While Medicare might pay for short-term, skilled rehabilitative services in a nursing home if you’ve spent at least three days in the hospital as an inpatient, it won’t pay for long-term custodial services.


To learn more about pre-authorization services for your medical practice, reach out to our team of prior authorization professionals at AuthNet today for a free demo of our services.