Use the External Review Process, not just the insurer’s internal appeal.
The Supreme Court for Your Health Claim
An internal appeal is like asking the judge who just ruled against you to please reconsider his own decision. He is part of the same court system and is likely to defend his original verdict. An External Review is completely different. It’s like taking your case to a neutral, independent Supreme Court. A doctor who has no connection to your insurance company reviews the facts and makes a binding decision. This is your most powerful right, moving your case from their biased courtroom into a fair and impartial one.
Stop accepting a denial for “Not Medically Necessary.” Do get a detailed letter from your doctor explaining why it is, instead.
Your Doctor’s Letter Is the Expert Witness
A denial for “Not Medically Necessary” is the insurer saying, “We don’t think you need this.” Your doctor’s detailed letter is the expert witness who stands up in court and proves them wrong. A simple prescription is a request; a letter of medical necessity is a closing argument. It explains your specific condition, details the treatments that have already failed, and proves why this particular procedure or drug is the one critical tool required to fix the problem. It replaces their vague opinion with your doctor’s expert facts.
Stop just accepting the denial letter. Do request the specific clinical guidelines the insurer used to make their decision, instead.
Make Them Show You Their Secret Rulebook
When an insurer denies your claim, they are making a call based on their own internal rulebook, called “clinical guidelines.” Accepting their denial without seeing that rulebook is like accepting a referee’s bad call without asking what rule you broke. Demanding a copy of the specific guideline they used forces them to put their cards on the table. You and your doctor can then see if they misinterpreted their own rules, or if their rulebook is outdated, allowing you to attack the very foundation of their denial.
The #1 secret for getting an experimental treatment covered is to find peer-reviewed medical studies that support it.
Don’t Just Say It Works, Prove It With a Blueprint
Asking an insurer to cover an “experimental” treatment is like asking a builder to use a radical new material. They will say no because it’s unproven. Your opinion, or even your doctor’s, is not enough. Peer-reviewed medical studies from established journals are the official engineering blueprints. They are the undeniable, scientific proof that this new material has been tested, that it is safe, and that it works. This evidence transforms your request from a risky gamble into a sound, data-driven investment in your health.
I’m just going to say it: Your doctor’s office’s billing department makes mistakes that can lead to denials.
A Typo on a Package Can Send It to the Wrong Country
Think of your health claim as a package that needs to be delivered to the insurance company for payment. The billing codes are the address label. If the billing department puts one wrong number on that label—the wrong zip code—the package will be marked “undeliverable” and sent back. Millions of claims are denied not because of your health, but because of a simple typo made by a busy office worker. Always suspect a simple clerical error is the real culprit behind your denial.
The reason your pre-authorization was denied is because of a single incorrect diagnostic code.
The Wrong Key Will Never Open the Right Lock
Getting a pre-authorization is like trying to open a specific, high-tech lock. Your diagnosis is the key, and the diagnostic code is the unique pattern cut into that key. Your doctor knows you need to get through the door, but if their billing office accidentally uses a key with a slightly different pattern—an outdated or incorrect code—the lock will not open. The denial isn’t a judgment on your need for treatment; it’s just the computer system stating that the wrong key was used.
If you’re still not getting an itemized bill, you’re losing the ability to spot and fight errors.
You Wouldn’t Pay for a Cart of Unpriced Groceries
Imagine a grocery store handing you a bill for $800 but refusing to give you a receipt showing what you bought. You’d never pay it. A hospital’s summary bill is that mystery total. The itemized bill is the detailed receipt. It lets you be the detective, scanning for mistakes like being charged for a medication you never received or for a full-hour procedure that only took 15 minutes. Without that itemized receipt, you are blindly paying for whatever is in their cart, errors and all.
The biggest lie you’ve been told is that you can’t fight a denial that’s “not a covered benefit.”
The Rulebook Might Have a Secret Exception Clause
When an insurer says something is “not a covered benefit,” it sounds final, like a rule carved in stone. But it’s not. Often, what they mean is that it’s not covered for your specific diagnosis. However, your policy’s rulebook might have a secret exception clause stating it is covered for a different diagnosis you also have. Or, state law may mandate coverage for it regardless of what the policy says. It’s not a closed door; it’s a challenge to find the other key that opens it.
I wish I knew about Patient Advocate Foundations when I was first facing a mountain of medical bills.
The Expert Guide for a Dangerous Mountain Climb
Facing a huge medical bill denial is like being told you must climb a dangerous, unfamiliar mountain, alone and without gear. You’re terrified and certain to fail. A Patient Advocate Foundation is like a team of expert Sherpas who show up and say, “Don’t worry, we’ve climbed this mountain a thousand times.” They are non-profits that provide professional case managers, for free, who know exactly how to navigate the appeals process, find financial aid, and guide you safely to the summit.
99% of people make this one mistake when their claim is denied: not checking their Explanation of Benefits (EOB) for coding errors.
The Detective Who Ignores the Most Obvious Clue
Your Explanation of Benefits (EOB) is the official “crime scene report” for your denied claim. It contains the most important clue: the exact billing codes the provider submitted. Not checking these codes is like a detective ignoring the fingerprints left on the murder weapon. A quick search online can reveal that the code used was for a screening test instead of a diagnostic test, or for an adult instead of a child. This single, obvious clue is often the key to solving the entire case.
Use your state’s Department of Insurance for health claim issues, not just for property damage.
The Same Sheriff Polices Every Part of Town
You know to call the Department of Insurance when your home insurer won’t pay for a new roof, but most people don’t realize that the very same sheriff polices the health insurance part of town, too. They have a dedicated health insurance division that has the power to investigate your complaint, force the insurer to respond, and penalize them for breaking the law. It’s a powerful, free, and under-utilized consumer protection tool that can bring order to your health claim chaos.
Stop letting them deny a claim for “pre-existing condition.” Do check the specific look-back period in your policy, instead.
The Crime They Can Only Charge You for if It Was Recent
A “pre-existing condition” denial is like being accused of a crime. But the law—your policy—has a statute of limitations, called a “look-back period.” The insurer can only deny your claim if your treatment for that condition happened within that specific window of time (e.g., the last 6 months) before your policy started. You must find that look-back period in your contract and then check your medical records. If their “evidence” is from outside that window, they have no case against you.
Stop fighting the hospital billing department alone. Do ask for their financial assistance or charity care program information, instead.
The Secret Financial Aid Office Hidden in the Hospital
Fighting with a hospital billing department is like arguing with a bank teller. They can only follow the rules they’ve been given. But almost every non-profit hospital has a secret financial aid office, like a university. They have legal obligations to provide “charity care” or financial assistance. By asking for their application, you move from arguing with the teller to speaking with the financial aid officer, who has the power to reduce your bill based on your income, or even forgive it entirely.
The #1 hack for appealing a “step therapy” requirement is to have your doctor document adverse effects from the preferred drug.
The Shortcut That Opens When the Main Road Is a Dead End
“Step therapy” is when your insurer makes you try their cheap, preferred drug first. It’s like forcing you to take a specific road. The #1 way to get a shortcut to the drug you actually need is to prove that their road is dangerous. If your doctor can document that you tried their preferred drug and it caused a bad side effect (an adverse reaction), it’s like a “road closed” sign. It legally obligates the insurer to open the shortcut and approve the next “step” drug your doctor originally wanted.
I’m just going to say it: The in-network doctor you saw may have used an out-of-network lab or anesthesiologist without your knowledge.
The Hidden Passengers Who Cost You a Fortune
You carefully chose an in-network surgeon and hospital, like booking a flight on your preferred airline. But you didn’t know that the anesthesiologist and the pathologist who read your lab results were “hidden passengers” who don’t actually work for the airline. They are independent contractors who don’t have the same deal with your insurer. This surprise “balance bill” is not your fault. It’s the result of a deceptive system, and new laws are making it easier to fight these unfair charges.
The reason your emergency room claim was denied as “not a true emergency” is because of your final diagnosis, not your initial symptoms.
Judging the Fire by the Ashes, Not the Alarm
Imagine you call the fire department because you see thick, black smoke pouring from your windows. It turns out you just burned a roast. Denying an ER claim is like the fire department billing you because it wasn’t a “real” fire. The law says they must judge the situation based on your symptoms when you called for help (the smoke), not the final outcome (the roast). If a reasonable person would think it was an emergency, the insurer is required to cover it.
If you’re still paying a bill that’s in dispute, you’re losing your leverage to negotiate.
Don’t Pay the Ransom Before the Negotiation Is Over
A disputed medical bill is a negotiation. Your most powerful piece of leverage is the money they want from you. Paying the bill while you are still appealing the denial is like paying the full ransom amount to a kidnapper and then trying to negotiate for a discount. Once they have your money, you have zero power. They have no incentive to help you, answer your calls, or fix the problem. Keep your money until the dispute is fully resolved and a final, correct amount has been agreed upon.
The biggest lie you’ve been told is that your insurer has your best health interests at heart.
They Are a Bank, Not a Doctor’s Office
Your health insurance company is not a healthcare company; it is a financial services company. It’s a bank. Their primary legal duty is not to your health, but to their shareholders’ profit. They make money by collecting the maximum in premiums while paying out the minimum in claims. While they employ doctors, their business model is fundamentally about managing financial risk, not about providing medical care. They are not your doctor; they are the bank that your doctor has to beg for money.
I wish I knew that I could negotiate a cash price with a provider that is often cheaper than my insured rate.
The Secret “Cash Only” Discount That Beats the “Official” Price
Your insurance company has negotiated a set of “discounted” rates with your doctor. But here’s the secret: you can often get an even bigger discount by becoming your own insurance company. Ask your provider, “What is your best cash price if I pay you directly and don’t involve insurance at all?” Because they avoid the paperwork, delays, and hassle of dealing with insurers, they will often offer a prompt-pay cash price that is significantly lower than the rate your own insurance company “negotiated” for you.
99% of patients make this one mistake: not knowing their rights under the No Surprises Act.
The New Shield That Protects You From Financial Ambush
For years, getting a surprise out-of-network bill was like being ambushed by a hidden gunman. The No Surprises Act is a new, powerful shield. This federal law makes it illegal for out-of-network providers at in-network hospitals to send you a surprise “balance bill” for emergency care and certain other services. It forces them to negotiate directly with your insurer. Knowing you have this shield allows you to confidently challenge and defeat those terrifying, unexpected medical bills.
Use the term “continuity of care” in your appeal, not just “I like my doctor.”
A Legal Term, Not a Personal Preference
Telling your insurer you want to keep seeing a doctor who just went out-of-network because you “like them” is a weak, personal plea. Using the legal term “continuity of care” is a powerful strategic move. This term applies if you are in the middle of a complex treatment (like pregnancy or chemotherapy). It argues that switching doctors now would be medically dangerous. It transforms your appeal from a preference into a matter of patient safety, which is a much stronger argument for them to approve.
Stop accepting a denial for “investigational” treatment. Do prove it’s the standard of care in other regions, instead.
If It’s Normal in Ohio, It’s Not “Experimental” in Texas
An insurer will call a treatment “investigational” if it’s new or uncommon in your specific area. It’s like them saying a new type of engine is “untested.” Your job is to prove that this engine is already being used successfully in other major cities. By finding guidelines from leading hospitals or medical associations that show this treatment is the “standard of care” elsewhere, you prove it’s not a risky experiment. It’s a proven technology that just hasn’t arrived in your town yet.
Stop taking the first “no” on a prescription drug denial. Do ask your doctor to file for a formulary exception, instead.
The Secret Override Code for Your Prescription
A “formulary” is the list of drugs your insurance company agrees to pay for. If your drug isn’t on the list, the claim is automatically denied. It’s a computer saying no. But there is a secret override code. A “formulary exception” is a special request your doctor can file that explains why you, due to your unique medical condition, need that specific drug and cannot use the ones on their approved list. It’s the human appeal that bypasses the computer’s automatic rejection.
The #1 secret for getting mental health services covered is to know your rights under the Mental Health Parity and Addiction Equity Act.
The Law That Says a Brain Is Part of the Body
The Parity Act is a powerful federal law with a simple principle: insurance companies must treat illnesses of the brain (like depression or addiction) the same way they treat illnesses of the body (like diabetes or a broken leg). They cannot have stricter limits or require more pre-authorizations for mental healthcare than they do for physical healthcare. Citing this law in your appeal is your strongest weapon, reminding them they are legally required to provide equal coverage for your mental health.
I’m just going to say it: Your insurance company is counting on you being too sick and tired to fight their denial.
The Strategy of Exhausting the Wounded
Denying your claim is a calculated business strategy. The insurance company is like a general in a war who knows their opponent is already sick and wounded. They know that the process of fighting—the confusing paperwork, the long phone calls, the endless delays—will exhaust you. They are betting that you will eventually become too tired, too sick, and too overwhelmed to continue the battle. They are not just denying your claim; they are trying to wear you down until you surrender.
The reason your therapy sessions aren’t being covered is because your provider isn’t using the correct billing codes for your diagnosis.
The Wrong Label on the Medicine Bottle
Your therapist knows exactly how to treat your condition, but their billing staff might be putting the wrong label on the bottle. They might be using a generic, vague billing code for “talk therapy” when your insurance requires a specific code for your diagnosed condition, like “Cognitive Behavioral Therapy for Anxiety.” The denial isn’t about the validity of your treatment; it’s a bureaucratic mismatch between the therapy you’re getting and the code being used to describe it on a form.
If you’re still not keeping a detailed log of your symptoms and treatments, you’re losing evidence for your appeal.
The Lab Notebook for Your Body’s Experiment
Appealing a denial requires evidence that your treatment is working or necessary. A detailed log of your symptoms, side effects, and progress is your personal lab notebook for the experiment being conducted on your body. This log—”Monday: Took medication, felt nauseous. Tuesday: Pain level was a 3 out of 10 after therapy.”—is the hard data that proves your case. Without it, your appeal is based on hazy memories. With it, you have a scientific record of facts they cannot ignore.
The biggest lie you’ve been told is that a “participating provider” will never balance bill you.
The “In-Network” Sticker Can Sometimes Peel Off
A “participating” or “in-network” provider has a contract with your insurer. But that contract might not cover every single service they offer. It’s like a restaurant that accepts your favorite gift card, but only for the main courses, not for drinks or dessert. The provider might perform a specific test or procedure that is excluded from their contract, which allows them to bill you for the difference. You must always confirm that the specific service is covered, not just the doctor.
I wish I knew to get a second opinion from an in-network doctor to support my out-of-network claim.
The Expert Witness from Their Own Team
When you ask your insurer to cover an expensive, out-of-network specialist, they see it as you bringing in a hired gun. It’s easy for them to dismiss. The ultimate strategy is to first get a second opinion from a respected doctor inside their own network who agrees with the out-of-network doctor’s plan. Now, you are walking into the appeal with an expert witness from their own team who is testifying on your behalf. This makes their argument almost impossible to defend.
99% of people make this one mistake: not asking for the medical reviewer’s credentials.
You Have the Right to Know Who Is Judging You
When your claim is denied for medical reasons, the decision was made by a person—a doctor or nurse working for the insurer. You have the right to know who that person is and what their qualifications are. Was your complex cardiac claim denied by a pediatrician? Was your rare neurological condition reviewed by a retired dermatologist? Asking for the reviewer’s name and medical specialty can reveal a stunning lack of relevant expertise, which is a powerful point for your appeal.
Use a HIPAA release form to get your complete medical records, not just the summary the hospital provides.
The Director’s Cut, Not the Movie Trailer
When you ask for your medical records, the hospital often gives you a short summary, known as the “abstract.” This is the movie trailer. A standard HIPAA release form, however, gives you the right to the entire, complete record—the full director’s cut. This includes the doctor’s private notes, nurses’ logs, and billing information that can contain crucial evidence for your appeal. You are legally entitled to the whole story, not just the convenient summary they want to show you.
Stop letting them deny your child’s therapy as “educational” rather than “medical.” Do get a letter of medical necessity from a pediatrician, instead.
The Doctor’s Note That Changes the Category
Insurance companies will try to avoid paying for therapies (like speech or occupational therapy) by claiming they are for “educational” needs, which is the school’s responsibility. This is a classic cost-shifting tactic. The way to defeat it is with a powerful letter of medical necessity from your child’s pediatrician. This letter acts as an official re-categorization, explaining that the therapy is not for school, but is essential to treat an underlying medical diagnosis, making it the insurer’s responsibility.
Stop giving up on a durable medical equipment denial. Do get a prescription and justification from your doctor, instead.
The Blueprint That Proves You Need the Tool
A request for medical equipment, like a special wheelchair or hospital bed, can be denied if it looks like a mere convenience. To get it approved, you need to prove it’s a critical tool. A prescription from your doctor is the first step. But the secret is the detailed letter of justification that goes with it. This letter is the blueprint that explains exactly how this specific piece of equipment is essential for you to perform your daily activities, transforming it from a “want” into a “need.”
The #1 hack for a successful appeal is a letter from your doctor written to the reviewing physician, not to the insurance company.
The Doctor-to-Doctor Backchannel
An appeal letter from your doctor to the faceless “Insurance Company” is often ignored. The ultimate hack is to have your doctor request a “peer-to-peer” review. This is a direct phone call or letter from your treating physician to the doctor at the insurance company who is reviewing your case. It takes the bureaucrats out of the middle and allows the two medical professionals to have a direct conversation, where your doctor can advocate for your care, expert to expert.
I’m just going to say it: The automated systems that process claims deny millions of legitimate claims by default.
The Robot Gatekeeper That’s Programmed to Say “No”
The vast majority of health insurance claims are not initially reviewed by a human. They are scanned by a computer system programmed with thousands of rules. If your claim has a single coding mismatch or doesn’t fit a perfect rule, the robot gatekeeper automatically denies it. The denial is not a medical judgment; it’s a computer error. Your first appeal is often just your first attempt to get your case past the robot and into the hands of a thinking human being.
The reason your long-term care claim was denied is because you can’t prove you need assistance with two “Activities of Daily Living.”
The Six Keys to Unlocking Your Benefits
A long-term care policy is like a vault with a very specific lock. To open it, you must prove you need help with a certain number (usually two) of the six “Activities of Daily Living” (ADLs): bathing, dressing, eating, toileting, continence, and transferring. Your denial is often because your documentation didn’t clearly prove your inability to perform these specific tasks. To win, you must provide detailed evidence from doctors and caregivers that speaks directly to these six magic keys.
If you’re still talking to customer service reps, you’re losing time; ask to be escalated to a clinical appeals specialist.
Stop Talking to the Teller, Demand to See the Bank Manager
The frontline customer service representative is a bank teller. They can only read the script on their screen and have no authority to change anything. Continuing to explain your complex medical situation to them is a waste of breath. The moment you realize they can’t help, you must use the magic words: “I need to be escalated to a clinical appeals specialist or a case manager.” This is your demand to stop talking to the teller and be put on the phone with the bank manager.
The biggest lie you’ve been told is that you can’t appeal a denial after the deadline has passed.
The Deadline Can Be Bent if You Have a Good Reason
Insurance companies present their appeal deadlines as if they are a solid steel wall. But for many situations, especially with employer-sponsored plans, that wall can be flexible. If you have a good reason for missing the deadline—such as being in the hospital, not receiving the denial letter, or waiting for medical records—you can request an extension. The key is to document the reason for your delay. It’s not a guaranteed entry, but it’s a door that can often be unlocked.
I wish I knew that I could file a complaint with the U.S. Department of Labor for my employer-sponsored plan.
The Federal Referee for Your Company’s Health Plan
If your health insurance comes from your job, it is likely governed by a powerful but little-known federal law called ERISA. The referee for this law is not your state’s Department of Insurance; it’s the U.S. Department of Labor. They have a special division that handles complaints about employer-sponsored health plans. Filing a complaint with them is a powerful escalation that gets the attention of your employer and the insurance company, as it brings in the federal government as a watchdog.
This one small action of checking for network adequacy will change how you choose your health plan forever.
Before You Buy the Car, Check to See if It Has Roads
Choosing a health plan is like buying a car. We look at the price (premium) and the gas mileage (deductible). But we forget to check the most important thing: the map of roads the car is allowed to drive on. “Network adequacy” means checking that map to see if there are actually doctors and hospitals you need, near you, who accept the plan. Choosing a plan with a cheap premium but no local doctors is like buying a fancy car in a town with no roads.
Use the Summary of Benefits and Coverage (SBC) document to fight your claim, not just the marketing brochure.
The Legal Contract, Not the Glossy Advertisement
The colorful brochure you got during open enrollment is an advertisement. The Summary of Benefits and Coverage (SBC), however, is a legally mandated, standardized document that is part of your contract. It’s written in plain English and clearly lists what the plan covers and what your costs are. If your insurer denies something that the SBC says is covered, that document becomes your most powerful piece of evidence. It’s the difference between showing the judge a TV commercial versus the signed contract.
Stop accepting a denial for a high-cost drug. Do investigate the manufacturer’s patient assistance programs, instead.
The Secret Discount Program from the People Who Make the Medicine
When your insurer denies a very expensive drug, there is often a secret back door. The pharmaceutical company that makes the drug almost always has a “Patient Assistance Program” or a co-pay card. They know insurers will deny their expensive product, so they create these programs to help you get it for a reduced price, or even for free. Their goal is to get you on the medication, and they will often help you navigate the insurance appeals process themselves.
Stop letting a denial for “timely filing” stand. Do ask your provider for proof of their original submission date, instead.
Don’t Pay the Price for Their Mail Getting Lost
A “timely filing” denial is the insurer claiming your doctor’s office sent the bill in too late. But it’s not your fault. It’s a dispute between the doctor and the insurer. You are the customer caught in the middle. The first step is to demand that your doctor’s office provide you with proof—like an electronic submission receipt—that they sent the original claim on time. This evidence proves they did their job, and the fault lies with the insurer for losing the claim.
The #1 secret for getting a genetic test covered is to show a family history that makes it medically necessary.
Your Family Tree Is the Treasure Map to Coverage
Asking for a genetic test without a reason is like asking an insurer to pay for a treasure hunt. They will say no. To get it covered, you must provide them with the treasure map: your family medical history. If you can show, through medical records, that you have a first-degree relative who had a specific type of cancer or genetic condition, the test is no longer a random hunt. It becomes a medically necessary diagnostic tool to see if you are carrying the same risk.
I’m just going to say it: Health insurance companies deny claims from certain providers more frequently as a negotiation tactic.
The Squeeze Play to Force a Doctor’s Hand
An insurance company is in a constant, tough negotiation with doctors over payment rates. One of their most powerful and ruthless tactics is to start systematically denying or delaying claims from a specific doctor’s office. This “squeeze play” puts immense financial pressure on the doctor, who is suddenly not getting paid. The goal is to force the doctor to accept a lower reimbursement rate in their next contract. You, the patient, are just the pawn in their high-stakes business game.
The reason your dental claim was denied is because of a “missing tooth” clause in your policy.
The Pre-Existing Condition of Your Mouth
A “missing tooth” clause is one of the most common and frustrating traps in dental insurance. It’s a pre-existing condition clause for your mouth. It says that if a tooth was already missing before you signed up for the policy, they will not pay for anything to replace it, like a bridge or an implant. They will cover the cleaning of your other teeth, but that empty space is considered a problem you had before you joined, and they will not pay to fix it.
If you’re still not documenting every phone call with your insurer, you’re losing valuable evidence for your state complaint.
Your Call Log Is the Security Footage of Their Broken Promises
When you file a complaint, your state regulator will ask for evidence. Your memory of a dozen frustrating phone calls is not evidence. A detailed call log is. Every time you call, write down the date, time, name of the representative, and a summary of what they said. This log is the undeniable, time-stamped security footage that proves the pattern of misinformation, delays, and broken promises. It transforms your complaint from a “he said, she said” dispute into a documented case of misconduct.
The biggest lie you’ve been told is that the price of a medical procedure is non-negotiable.
The Sticker Price Is a Fantasy, Not a Final Price
The price a hospital puts on its bill is like the ridiculously high sticker price on a new car. Nobody is actually expected to pay that amount. It is a completely made-up number designed as a starting point for negotiations with insurance companies. If you are uninsured or paying yourself, you have the power to negotiate that price way down. You can research what Medicare pays for that service and use that as leverage to get a price that is based on reality, not their fantasy.
I wish I knew about the concept of a “clean claim” and what it legally requires from an insurer.
The Shot Clock That Forces Them to Play
A “clean claim” is a bill submitted by your doctor that has no typos or errors. And once the insurer receives it, a secret shot clock starts ticking. Most states have “prompt pay” laws that say an insurer has a specific number of days (usually 30 or 45) to either pay or deny that clean claim. They are not allowed to let it sit on a desk forever. Knowing about this legal shot clock gives you the power to file a complaint if they are illegally delaying the game.
99% of people make this one mistake: thinking their employer has any say in their health insurer’s claim decisions.
Your Boss Owns the Bus, but They Don’t Drive It
Your employer chooses the health insurance plan; it’s like they bought the bus that takes you to the doctor. But they do not drive it. The insurance company is the driver, and they have total control over the route and the stops. Due to medical privacy laws (HIPAA), your HR department has no access to your claim information and no legal authority to tell the insurer to approve or deny it. They can be a helpful advocate, but they are not the ones making the decision.