Talking to a health insurance company feels like walking through a minefield. One wrong word, and your claim could be denied, reduced, or flagged for investigation.
So, what not to tell the insurance company – whether you are a patient or a provider?
Here are 7 phrases to avoid, why they are dangerous, and what to say instead.
Phrase #1: “I’m not sure what caused it.”
Why it’s dangerous: If you admit you do not know the cause, the insurer may deny coverage – especially for accidents or injuries that could be work-related or related to a pre-existing condition (for non-ACA plans).
What they hear: “This might not be covered.”
Say this instead: Describe only the facts you are certain about. “This injury occurred on [date] when I [factual description].” If asked about cause you do not know: “I don’t have that information at this time.”
Phrase #2: “I think it was a pre-existing condition.”
Why it’s dangerous: For grandfathered or non-ACA plans, pre-existing conditions can be excluded entirely. Even for ACA plans, giving this answer can trigger a lengthy medical record review.
What they hear: “Don’t pay this claim.”
Say this instead: “My symptoms started on [date].” Let your doctor determine the diagnosis. Do not offer historical speculation.
Phrase #3: “That was just a routine checkup.”
Why it’s dangerous: If you call a visit “routine,” the insurer may pay only for preventive services – not for any problem addressed during that visit.
What they hear: “Only pay the preventive rate.”
Example: You mention a new back pain during your annual physical. If you tell the insurer “it was just a routine checkup,” they may deny the portion related to back pain evaluation.
Say this instead: Describe the actual reason for the visit. “I had my annual preventive exam, and I also discussed a new symptom with my doctor.”
Phrase #4: “That seems reasonable” (when they offer a low settlement)
Why it’s dangerous: Insurance adjusters are trained to ask questions like “Don’t you think $X is fair for that procedure?” If you agree, you have just negotiated against yourself.
What they hear: “I accept this lower amount.”
Say this instead: “I need to review the allowed amount against my explanation of benefits (EOB) before agreeing to anything.”
Phrase #5: “I didn’t think I needed prior authorization.”
Why it’s dangerous: Admitting you skipped prior authorization is an automatic denial. The insurer will not pay, and you cannot appeal based on “I didn’t know.”
What they hear: “This is a valid denial.”
Say this instead: If you are a provider: “Please check if prior authorization was required for this code on this date. If it was, we can request retro authorization.” If you are a patient: “My doctor’s office handled the authorization. Can you confirm if it was submitted?”
Phrase #6: “The hospital bill seems high.”
Why it’s dangerous: Insurers love when patients say this. They may use your statement to justify paying less than the contracted rate – leaving you with a surprise balance bill.
What they hear: “Pay less than the full amount.”
Say this instead: “Please process the claim according to my plan’s allowed amounts and my in-network benefits.”
Phrase #7: Personal opinions about your provider.
Why it’s dangerous: Never say anything negative about your doctor, hospital, or their documentation. Insurers record calls and may use your statements to deny claims for “lack of medical necessity” or “questionable documentation.”
What they hear: “Another reason to deny.”
Say this instead: Stick to factual questions. “What additional documentation do you need to process this claim?” Do not offer opinions about your provider’s competence or billing practices.
Summary Table: What Not to Say vs. What to Say Instead
| Don’t Say | Say Instead |
|---|---|
| “I’m not sure what caused it.” | “The injury occurred on [date]. I don’t have additional information at this time.” |
| “I think it was pre-existing.” | “My symptoms started on [date].” |
| “That was just a routine checkup.” | “I had my annual preventive exam and discussed a new symptom.” |
| “That seems reasonable.” | “I need to review this against my EOB.” |
| “I didn’t get prior authorization.” | “Can you check if prior authorization was required?” |
| “The bill seems high.” | “Please process according to my plan’s allowed amounts.” |
| Negative opinions about provider | “What documentation do you need to process this claim?” |
Why Insurance Companies Ask These Questions
Insurance companies are for-profit businesses. Their adjusters are trained to:
- Deny first – Many people do not appeal.
- Ask leading questions – To get you to say something that reduces their payout.
- Record everything – Your words can be used against you later.
Remember: The person on the phone is not your friend or advocate. They work for the insurance company. Be polite, but do not volunteer information.
What This Means for Healthcare Providers
As a medical practice, you face similar risks when talking to payers about claim denials, prior authorizations, or appeals.
What not to say to a payer as a provider:
| Don’t Say | Why | Say Instead |
|---|---|---|
| “The coder must have made a mistake.” | Triggers automatic audit | “Please review the medical records – they support this code.” |
| “We forgot to get prior auth.” | Irreversible denial | “Can we request retroactive authorization based on medical necessity?” |
| “Just pay whatever is fair.” | Lowers your reimbursement | “Please pay the contracted rate for this service.” |
| “I’ll waive the patient’s balance.” | May violate your payer contract | “I need to review our agreement before making any patient balance adjustments.” |
How All State RCM Protects Your Practice
We talk to insurance companies every day – so you do not have to. Our trained denial management and billing specialists know:
- What to say (and what not to say) to each payer
- How to appeal denials without triggering audits
- How to request prior authorizations efficiently
- How to document conversations for appeal evidence
Result: Less than 1% rejections and 97% claim reimbursement.
Real Example: What Happens When You Say the Wrong Thing
A small cardiology practice called UnitedHealthcare about a denied claim. The office manager said: “I think our coder just forgot the modifier.”
Result: The denial was upheld. UHC flagged the practice for “coding errors” and audited 100 random claims – costing the practice 40 hours of staff time.
What should have been said: “Please review the medical record. The documentation supports the code as billed. If a modifier is needed, please specify which one.”
That simple change in phrasing could have led to a simple correction, not an audit.
The Bottom Line: What Not to Tell the Insurance Company
| For Patients | For Providers |
|---|---|
| Do not speculate about cause or pre-existing conditions | Do not admit coding errors without documentation |
| Do not agree to low settlements immediately | Do not waive balances without checking contracts |
| Do not call a visit “routine” if you had a problem | Do not say “we forgot” prior authorization |
| Do not give opinions about your provider | Do not ask for “whatever is fair” |
The golden rule: Answer only what is asked. Do not volunteer extra information. When in doubt, say: “I need to review my documents before answering that.”
