Health Care Helpline Archives - KFF Health News

Listen: Why Do I Need Prior Authorization?

Sarah Boden — Tue, 17 Feb 2026 10:00:00 +0000

Listen in as “Life Kit” host Marielle Segarra and health reporter Sarah Boden untangle the red tape that can make the prior authorization process frustrating.

When the doctor says you need a prescription or treatment, sometimes you need approval from your health insurance first. That’s called prior authorization. Without that sign-off, insurance won’t pay.

What triggers the need for prior authorization is not fully clear. It’s another “black box” part of the health care system.

You might think insurance companies mostly target expensive treatments or care approaches when a disagreement over effectiveness prompts a prior authorization review. Often that’s not the case. Some doctors complain they spend a lot of time filling out paperwork to try to secure approval for medicine or treatments that are routine.

In the meantime, patients can be left in pain, while their medical conditions worsen.

Health Care Helpline helps you navigate the health system hurdles between you and good care. Send us your tricky question and we may tap a policy sleuth to puzzle it out. Share your story.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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To Knock Down Health-System Hurdles Between You and HIV Prevention, Try These 6 Things

Zach Dyer and Oona Zenda — Mon, 05 Jan 2026 10:00:00 +0000

When Matthew Hurley was looking to take PrEP to prevent HIV, the doctor hadn’t heard of the medicine, and when he finally did prescribe PrEP, the bills sent to Hurley were expensive … and wrong. “I decided to write in because the process was really super frustrating.” At one point, Hurley asked, “Am I just going to stop this medication to stop having to deal with these coding issues and these scary bills?”

— Matthew Hurley, 30, from Berkeley, California

A couple of years ago, Matthew Hurley got the kind of text people fear.

It said: “When was the last time you were STD tested?”

Someone Hurley had recently had unprotected sex with had just tested positive for HIV.

Hurley went to a clinic and got tested. “Luckily, I had not caught HIV, but it was a wake-up call,” they said.

That experience moved Hurley to seek out PrEP, shorthand for preexposure prophylaxis. The antiretroviral medication greatly reduces the chance of getting HIV, the virus that causes AIDS. The therapy is 99% effective at protecting people against sexual transmission when taken as prescribed.

Hurley started PrEP and all was well for the first nine months — until their health insurance changed and they started seeing a new doctor: “When I brought PrEP up to him, he said, ‘What’s that?’ And I was like, oh boy.”

Hurley, who is a librarian, went into teaching mode. They explained that the PrEP regimen they’d been on required daily pills and lab work every three months to look out for breakthrough infections or other health issues.

Hurley was surprised they knew more about PrEP than the physician. The FDA approved the first drug, Truvada, back in 2012, and Hurley lives in the San Francisco Bay Area, a place with one of the highest concentrations of LGBTQ+ people in the nation and a deep history of HIV and health care activism. Hurley said older friends and acquaintances who survived the AIDS epidemic shared the horror of living through a time when there was no effective treatment or drugs for prevention. Deciding to take PrEP felt like an empowering way to protect their health and their community.

So Hurley pushed the doctor, and after the physician did his own research, he agreed to prescribe PrEP.

Hurley got the care they needed, but they had to be the expert in the exam room.

“That’s a big burden,” said Beth Oller, a family medicine physician and board member of GLMA, a national organization of LGBTQ+ and allied health care professionals focused on health equity. “You really want someone you can just go in and talk [to] about your health concerns without feeling like you are having to educate and advocate for yourself at every turn.”

Oller said many queer people have had negative experiences during health care visits.

“I have a lot of patients who had not done preventive care for years because of the medical stigma,” she said.

Billing Headaches

Clearing the access hurdles to HIV prevention medicine was just the beginning. Hurley started receiving a string of bills for PrEP-related care. Blood test: $271.80. Office visit: $263.

Again, Hurley was surprised. They knew — even if the billing office didn’t — that under the Affordable Care Act most private insurance plans and Medicaid expansion programs are required to cover PrEP and ancillary services, like lab tests, as preventive with no cost sharing.

The bills for doctor visits and blood draws piled up.

Hurley would appeal the bill and get a denial almost every time. Then, they would appeal again.

Hurley shared a series of appeal letters for one service, in which the billing office acknowledged that blood work had been initially incorrectly coded as diagnostic. Once that was corrected, Hurley said, the insurer paid for the service.

That might sound quick or easy to resolve, but Hurley said it took “forever to get through the process.” They dealt with at least six incorrect bills over several months. Hurley estimated they spent more than 60 hours contesting the bills.

During that time, Hurley said, the billing department “is continuing to send me emails and bills that are saying, You’re overdue. You’re overdue. You’re overdue.”

Fed up with the hassles, Hurley decided to find a health provider (and billing office) better informed about PrEP. They settled on the AIDS Healthcare Foundation. The care team there was able to discuss the pros and cons of different PrEP regimens and knew how to navigate the formulary for Hurley’s insurance.

Hurley hasn’t gotten an unexpected bill since.

But siloing sexual health care and PrEP off from primary care hasn’t been ideal.

“I have multiple organizations that I have to deal with to get my holistic health dealt with,” Hurley said.

A provider doesn’t need to be an HIV specialist, an infectious disease expert, or a physician to prescribe PrEP. The Centers for Disease Control and Prevention encourages primary care providers to treat PrEP like other preventive medications.

To avoid some of the headaches Hurley faced, try these tips:

1. Find Out if PrEP Is Right for You

The CDC estimates 2.2 million Americans could benefit from HIV prevention drugs, but just over a quarter of that group have been prescribed them.

“Not enough people know about PrEP, and there are a number of people who know about PrEP but do not realize it’s for them,” said Jeremiah Johnson, executive director of PrEP4All, an organization dedicated to universal access to HIV prevention and medication.

According to the CDC’s clinical guidelines, PrEP can be prescribed as part of a preventive health plan to anyone who’s sexually active. It’s especially recommended for people who don’t use condoms consistently, intravenous drug users who share needles, men who have sex with men, and people in relationships with partners living with HIV or whose HIV status is unclear.

The vast majority of PrEP users are men. There are big race, gender, and geographical disparities in the distribution of HIV and the populations taking the prevention medicine. For example, based on the patterns of new infection in the U.S., a group that would benefit from PrEP is cisgender Black women, whose gender identity aligns with their sex assigned at birth.

2. Don’t Assume Your Provider Knows About PrEP

If your doctors aren’t well informed, start by educating yourself. There are also clinical guidelines and information you can share with your provider. Check your state or local health department for a how-to guide for prescribing PrEP. For example, the New York State Department of Health AIDS Institute has information for providers.

The CDC also has PrEP guidelines, but many of the agency’s websites dealing with LGBTQ+ health are in flux. Under the Trump administration, some HIV/AIDS resources have been taken down from federal websites. Others now have headers saying: “This page does not reflect biological reality and therefore the Administration and this Department rejects it.”

3. Get Lab Work In-Network

Johnson said Hurley’s experience with billing mistakes is common. “The lab expenses in particular end up being very tricky,” Johnson said.

For example, a doctor’s office may mistakenly code the lab work required for PrEP as a diagnostic test instead of preventive care. Patients like Hurley can end up with a bill they shouldn’t have to pay. If your doctor’s office is making mistakes, share the PrEP billing and coding guide from NASTAD, an association of public health officials who administer HIV and hepatitis programs.

Try to get your lab work done in-network. If the lab is out-of-network, Johnson said, it can be difficult to appeal.

If the bills keep coming, appeal them. And if you can’t resolve the dispute, Johnson said, file a complaint with the agency that regulates your insurance plan.

4. Look for Ways To Save

There are different kinds of PrEP. There are lower-cost, generic versions of Truvada, for example, sold as emtricitabine/tenofovir disoproxil fumarate, often shortened to FTC/TDF. Newer PrEP drugs Apretude and Yeztugo have list prices in the thousands of dollars. Check your insurance formulary and ask your doctor to prescribe medicine your plan will cover.

With many health care premiums dramatically increasing and millions at risk of losing Medicaid coverage, many people may go without health insurance this year. Drug manufacturers such as Gilead and ViiV have assistance programs for qualifying patients. If you have to pay out-of-pocket, prescription price comparison websites, like GoodRx, can help you find the pharmacies with the cheapest price.

5. Consider Telehealth

Telehealth is an increasingly popular option if you don’t live near an affirming provider or are looking for a more private way to get PrEP. In 2024, roughly 1 in 5 people on PrEP used telemedicine. Online pharmacies like Mistr and Q Care Plus offer PrEP without an in-person appointment, and lab work can be done at home. Some telehealth options have ways to lower the cost if you’re uninsured.

Telehealth can also broaden the number of doctors who are ready to prescribe PrEP. And some patients say speaking with a remote provider feels like a safer setting to talk about sexual health. “They’re in the comfort of their own bedroom or living room but can interface virtually with a provider. It can open up a lot of doors for honesty and trust,” said Alex Sheldon, executive director of GLMA.

6. Seek Out Affirming Care

GLMA created the LGBTQ+ Healthcare Directory, a searchable database of health care providers across the nation who identify as queer-friendly. As Hurley discovered, living in a major metro area is no guarantee your doctor is up to date on LGBTQ+ health care.

Ask locals you trust for recommendations. You might be surprised to find good options nearby.

Health Care Helpline helps you navigate the health system hurdles between you and good care. Send us your tricky question and we may tap a policy sleuth to puzzle it out. Share your story. The crowdsourced project is a joint production of NPR and KFF Health News.

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So Your Insurance Dropped Your Doctor. Now What?

Bram Sable-Smith and Oona Zenda — Wed, 29 Oct 2025 09:00:00 +0000

Last winter, Amber Wingler started getting a series of increasingly urgent messages from the local hospital in Columbia, Missouri, letting her know her family’s health care might soon be upended.

MU Health Care, where most of her family’s doctors work, was mired in a contract dispute with Wingler’s health insurer, Anthem. The existing contract was set to expire.

Then, on March 31, Wingler received an email alerting her that the next day Anthem was dropping the hospital from its network. It left her reeling.

“I know that they go through contract negotiations all the time … but it just seemed like bureaucracy that wasn’t going to affect us. I’d never been pushed out-of-network like that before,” she said.

The timing was awful.

The query: When a Missouri mom’s health insurance company couldn’t come to an agreement with her hospital, most of her doctors were suddenly out-of-network. She wondered how she would get her kids’ care covered or find new doctors. “For a family of five, … where do we even start?”

— Amber Wingler, 42, in Columbia, Missouri

Wingler’s 8-year-old daughter, Cora, had been having unexplained troubles with her gut. Waitlists to see various pediatric specialists to get a diagnosis, from gastroenterology to occupational therapy, were long — ranging from weeks to more than a year.

(In a statement, MU Health Care spokesperson Eric Maze said the health system works to make sure children with the most urgent needs are seen as quickly as possible.)

Suddenly, the specialist visits for Cora were out-of-network. At a few hundred bucks a piece, the out-of-pocket cost would have added up fast. The only other in-network pediatric specialists Wingler found were in St. Louis and Kansas City, both more than 120 miles away.

So Wingler delayed her daughter’s appointments for months while she tried to figure out what to do.

Nationwide, contract disputes are common, with more than 650 hospitals having public spats with an insurer since 2021. They could become even more common as hospitals brace for about $1 trillion in cuts to federal health care spending prescribed by President Donald Trump’s signature legislation signed into law in July.

Patients caught in a contract dispute have few good options. “There’s that old African proverb: that when two elephants fight, the grass gets trampled. And unfortunately, in these situations, oftentimes patients are grass,” said Caitlin Donovan, a senior director at the Patient Advocate Foundation, a nonprofit that helps people who are having trouble accessing health care.

If you’re feeling trampled by a contract dispute between a hospital and your insurer, here is what you need to know to protect yourself financially:

1. “Out-of-network” means you’ll likely pay more.

Insurance companies negotiate contracts with hospitals and other medical providers to set the rates they will pay for various services. When they reach an agreement, the hospital and most of the providers who work there become part of the insurance company’s network.

Most patients prefer to see providers who are “in-network” because their insurance picks up some, most, or even all of the bill, which could be hundreds or thousands of dollars. If you see an out-of-network provider, you could be on the hook for the whole tab.

If you decide to stick with your familiar doctors even though they’re out-of-network, consider asking about getting a cash discount and about the hospital’s financial assistance program.

2. Rifts between hospitals and insurers often get repaired.

When Brown University health policy researcher Jason Buxbaum examined 3,714 nonfederal hospitals across the U.S., he said, he found that about 18% of them had a public dispute with an insurance company sometime from June 2021 to May 2025.

About half of those hospitals ultimately dropped out of the insurance company’s network, according to Buxbaum’s preliminary data. But most of those breakups ultimately get resolved within a month or two, he added. So your doctors very well could end up back in the network, even after a split.

3. You might qualify for an exception to keep costs lower.

Certain patients with serious or complex conditions might qualify for an extension of in-network coverage, called continuity of care. You can apply for that extension by contacting your insurer, but the process may prove lengthy. Some hospitals have set up resources to help patients apply for that extension.

Wingler ran that gantlet for her daughter, spending hours on the phone, filling out forms, and sending faxes. But she said she didn’t have the time or energy to do that for everyone in her family.

“My son was going through physical therapy,” she said. “But I’m sorry, dude, like, just do your exercises that you already have. I’m not fighting to get you coverage too, when I’m already fighting for your sister.”

Also worth noting, if you’re dealing with a medical emergency: For most emergency services, hospitals can’t charge patients more than their in-network rates.

4. Switching your insurance carrier may need to wait.

You might be thinking of switching to an insurer that covers your preferred doctors. But be aware: Many people who choose their insurance plans during an annual open enrollment period are locked into their plan for a year. Insurance contracts with hospitals are not necessarily on the same timeline as your “plan year.”

Certain life events, such as getting married, having a baby, or losing a job, can qualify you to change insurance outside of your annual open enrollment period, but your doctors’ dropping out of an insurance network is not a qualifying life event.

5. Doctor-shopping can be time-consuming.

If the split between your insurance company and hospital looks permanent, you might consider finding a new slate of doctors and other providers who are in-network with your plan. Where to start? Your insurance plan likely has an online tool to search for in-network providers near you.

But know that making a switch could mean waiting to establish yourself as a patient with a new doctor and, in some cases, traveling a fair distance.

6. It’s worth holding on to your receipts.

Even if your insurance and hospital don’t strike a deal before their contract expires, there’s a decent chance they will still make a new agreement.

Some patients decide to put off appointments while they wait. Others keep their appointments and pay out-of-pocket. Hold on to your receipts if you do. When insurers and hospitals make up, the deals often are backdated, so the appointments you paid for out-of-pocket could be covered after all.

End of an Ordeal

Three months after the contract between Wingler’s insurance company and the hospital lapsed, the sides announced they had reached a new agreement. Wingler joined the throng of patients scheduling appointments they’d delayed during the ordeal.

In a statement, Jim Turner, a spokesperson for Anthem’s parent company, Elevance Health, wrote, “We approach negotiations with a focus on fairness, transparency, and respect for everyone impacted.”

Maze from MU Health Care said: “We understand how important timely access to pediatric specialty care is for families, and we’re truly sorry for the frustration some parents have experienced scheduling appointments following the resolution of our Anthem contract negotiations.”

Wingler was happy her family could see their providers again, but her relief was tempered by a resolve not to be caught in the same position again.

“I think we will be a little more studious when open enrollment comes around,” Wingler said. “We’d never really bothered to look at our out-of-pocket coverage before because we didn’t need it.”

Health Care Helpline helps you navigate the health system hurdles between you and good care. Send us your tricky question and we may tap a policy sleuth to puzzle it out. Share your story. The crowdsourced project is a joint production of NPR and KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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Listen: The Surprising Power of Pushback When Health Insurance Won’t Pay

Jackie Fortiér — Fri, 19 Sep 2025 09:00:00 +0000

Being denied insurance coverage can be both confusing and, at times, enraging. But mounting a skillful challenge can turn a “no” into “yes.”

From confusing policy language to coding errors to shifting insurer rules, a new episode of NPR’s “Life Kit” podcast explores why denials happen and how to avoid common pitfalls.

KFF Health News reporter Jackie Fortiér and “Life Kit” host Marielle Segarra discuss the intricate and sometimes infuriating process of dealing with denied health claims. It’s an issue lots of people run into — but don’t necessarily talk about.

Fortiér and Segarra offer tips backed by real-life examples and expert advice, so you’ll know whom to call, what to say, and how being a pest in the right way might save you money.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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Try This When Your Doctor Says ‘Yes’ to a Preventive Test but Insurance Says ‘No’

Jackie Fortiér and Oona Zenda — Thu, 21 Aug 2025 09:00:00 +0000

Health Care Helpline helps you navigate the hurdles between you and good health care. KFF Health News reporter Jackie Fortiér spoke with NPR’s Ari Shapiro about a Minnesota family facing big bills for their infant son’s hearing tests.

“My son was diagnosed with congenital CMV, a virus that can cause hearing loss. As part of this diagnosis, he will be required to have routine hearing tests every few months until he is 10 years old. I reached out to you because I wanted to know why my son’s hearing tests weren’t covered by our insurance and why we needed to pay for it.”

— Anna Deutscher, 29, from Minnesota, writing about her infant son, Beckham

Trying to figure out why her claim was denied took Anna Deutscher a lot of time and work.

Baby Beckham’s hearing screenings were preventive care, which is supposed to be covered by law. Every hearing test cost them about $350 out-of-pocket. Between those bills and Beckham’s other health costs, the family maxed out two credit cards.

“Everything just immediately goes right to trying to pay that debt off,” Deutscher said.

At times, she felt overwhelmed by her son’s medical needs, on top of working. Deutscher said she “didn’t know what else to do” when her insurance company kept saying no to her requests that it pay for the hearing tests.

No one wants to spend time fighting their health insurance company. Many people feel they don’t have the knowledge or stamina to do it. But if, like Deutscher, you’re denied for a preventive service, it may be worth it.

Here are a few tips — a slingshot and a few stones, so you can be David when facing a health care Goliath.

1. Check Your Policy

Read your plan documents to confirm whether the treatment or service is covered. Pay attention to any exclusions or limitations. Deutscher’s plan documents say hearing tests are not covered. But even when a sought-after benefit is excluded, that might not be the end of the line.

2. Is the Service Preventive?

Many types of preventive care are supposed to be covered without additional cost under the Affordable Care Act. If you receive a recommended preventive screening and have private insurance, including through the Affordable Care Act marketplace, there should be no copayment at the time of service, and you shouldn’t get a bill later. A small number of insurance plans are “grandfathered in,” which means you may not have the same rights and protections as the ACA provides. Check with your employer’s human resources benefits manager to find out for sure.

Here’s a list of preventive services health plans must cover and the list specific to children and young adults.

A physician recommended regular hearing screenings for the Deutschers’ baby, which the healthcare.gov list indicates should be considered preventive and covered by insurance. But JoAnn Volk, an insurance expert and a research professor at Georgetown University, said real life often doesn’t match what the law requires.

“It really does come down to everyone sort of being on their best behavior on the provider and plan side to truly interpret and follow what should be covered,” Volk said.

3. Peel Apart the Denial

If you’ve been denied coverage, you need to know why. Health insurance companies are required to explain every denial. The denial letter or your explanation of benefits should state the reason, which may be a coverage exclusion, incorrect coding, or a determination that the service was deemed not medically necessary. Follow up and ask for specific details about the denial and the criteria used, and request an explanation of benefits. Then use that information to build an appeal, being sure to address the reason for the denial.

4. File the Appeal

There are a few steps to know, but you don’t have to be a lawyer to figure them out. Usually there’s an appeal form to fill out. Visit your insurer’s website, check your explanation of benefits, or call your insurer and ask how to get started. The process typically includes writing a letter saying why you disagree with the denial. Include any medical records or test results that support your case and a copy of the federal guidelines that show the care is a covered, preventive service. If you can, ask your physician to write a letter explaining why the service is preventive and necessary.

Your insurance company has 30 to 60 days to respond, depending on your state and health plan. If your appeal is denied, try again. Some people win on the second go-round.

If your appeal is denied a second time, you can request an external medical review. That process is led by a medical professional who is supposed to make an unbiased decision. In California, for instance, many health plans fall under the jurisdiction of the Department of Managed Health Care.

“In 2023, 72% of health plan members that came to us and filed an independent medical review ended up getting the service that they requested,” said Mary Watanabe, who leads the department.

Keep deadlines in mind. How much time you have to file should be on your explanation of benefits. Your insurer is required by law to accept the external reviewer’s decision.

For more help starting an appeal or asking for an external review, visit healthcare.gov or your state insurance department.

5. Ask Human Resources for Help

If you get coverage through your job and you’re hitting roadblocks, consider emailing your human resources department. HR folks have contacts with the insurance companies you don’t and may save you a few calls to the 800 number on the back of your insurance card. Legally, HR is under no obligation to help, and covering a health service may not be in your employer’s financial interest. But sending HR the documents you prepared for the insurance appeal may prompt them to push the insurance company to take another look.

“The whole point of employers offering benefits is to attract and retain a solid workforce, right?” Volk said.

Making a case to HR may be a ramp toward getting the treatment or service covered the next time your company revises its health plan offerings, said Rhonda Buckholtz, a consultant who advises businesses on medical billing.

She said consumers can do a quick online search to see whether other large insurance companies in their area cover the health care service they need. That information can give you leverage, Buckholtz said.

Going to HR helped Deutscher. Eventually, her employer said it would cover the cost of hearing tests for baby Beckham for the current plan year. Deutscher’s employer has a self-funded plan, which gives companies the ability to customize benefits. It ultimately decided to add hearing tests as a standard benefit for all employees.

“It’s been like this constant cloud hanging over my head, so for that to suddenly be lifted, it didn’t feel real. I also have never gone to my HR for something like this before. I didn’t even know this was an option,” Deutscher said.

Health Care Helpline helps you navigate the health system hurdles between you and good care. Send us your tricky question and we may tap a policy sleuth to puzzle it out. Share your story. The crowdsourced project is a joint production of NPR and KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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This story can be republished for free (details).