Appealing Denied Medical Claims ⚕️

Have you noticed that more of your insurance claims and prior authorizations for procedures are getting denied? Unfortunately, this is a developing trend in health insurance coverage where the burden of challenging such a verdict may lie on you as a patient.

17% of in-network claims were denied in 2021. Insurer denial rates varied widely around this average, ranging from 2% to 49%

Background

Several analyses have found that medical claims are increasingly being denied. Crowe RCA had reported, “overall initial denial rates from 10.15% in 2020 to 11.2% in 2022, and then up again to 11.99% in the first three quarters of 2023,” after reviewing data from 1,800 hospitals and 200,000 physicians.¹ The Kaiser Family Foundation reported, “17% of in-network claims were denied in 2021. Insurer denial rates varied widely around this average, ranging from 2% to 49%.”²

🙅🏻‍♀️ What claims can be denied?

Denials can be made for various health-related items that include surgery, clinic visits, and even medication. The basis for denial can range from medical necessity to lack of timely paperwork filing.³

Several external and internal reviews have ruled on behalf of patients, so it doesn’t hurt to try!

Steps to Appeal your Denied Prior-Authorization or Claim

1. File an appeal for internal review through your health insurance provider. Your doctor’s office can do this, so confirm that they are filing one on your behalf.
   • Tip: Call your insurance company to ensure they have received all the necessary documentation.
2. File an appeal for external review, which is conducted by an independent third party.
   • Health insurance companies usually contract with at least three independent review agencies, one of whom will get your case randomly assigned.⁴
     • Protocols on who reviews your appeal may differ based on the insurance company and state of residence.
     • There might be a nominal fee incurred to file the paperwork.
   • For those individuals with Medicare, Medicaid, and state marketplace health insurance plans, this is a good start to learn about the appeals process: https://externalappeal.cms.gov/ferpportal/#/forms

💡 Tips

• Get a list of criteria that you need to meet in order to receive insurance coverage prior to the appeal process. Based on this list, you can verify your own symptoms and highlight the specific ones that are necessary.
• An external review can be filed prior to an internal review being completed, esp. for urgent matters.
• Keep note of deadlines for filing appeals. You don’t want to miss an opportunity to challenge the denied claim!
• Call your doctor’s office to seek help. They can be a good resource. However, remember that their system might be overburdened, so a gentle reminder will go a long way!

Is it a waste of time to appeal a denied claim or prior authorization?

Several external and internal reviews have ruled on behalf of patients, so it doesn’t hurt to try! Some findings indicate that, “over 40% of external review decisions are resolved in favor of the patient and, in those instances, the service or treatment must be covered by the health insurance company.”⁵

🔧 Handy Websites for additional information

https://www.insurance.ca.gov/01-consumers/101-help/upload/ConsumerAdvisoryIMR.pdf

• Provides guidance on the process of filing an internal and external review. Although information is geared towards California, many points are applicable nationwide.

https://externalappeal.cms.gov/ferpportal/#/home

• Provides guidance to Medicare, Medicaid, and state marketplace health insurance policy holders on filing internal and external reviews

https://www.insurance.pa.gov/Coverage/Documents/Health/FilingHealthInsuranceAppeals.pdf

• Contains sample letters for writing an internal or external appeal.

References

1. Muoio, Dave. Payers' increasing claims denials, delays 'wreaking havoc' on provider revenue cycles. https://www.fiercehealthcare.com/finance/payers-increasing-claims-denials-delays-wreaking-havoc-provider-revenue-cycles. Dec 14, 2023.

2. Pollitz, K. et al. Claims Denials and Appeals in ACA Marketplace Plans in 2021. [(https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/)(https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/)]. Feb. 29, 2023.

3. Marting, R. The Cure for Claims Denials. Fam Pract Manag. 2015;22(2):7-10.

4. (https://www.insurance.pa.gov/Coverage/Documents/Health/FilingHealthInsuranceAppeals.pdf)

5. (https://www.mass.gov/info-details/external-review-process-overview)