Why it is important to appeal a denied medical claim

My Patient Rights > Why it is important to appeal a denied medical claim

Why it is important to appeal a denied medical claim

Having health insurance should give patients a sense of comfort and security around the costs they should be paying for care. However, the influx of patient stories sharing their wrongful coverage denials appearing in the news cycle demonstrates this is not the case. More and more consumers have been left confused and frustrated when they receive bills in the mail for medical services they believed were covered by their insurance company. An insurer may have originally approved coverage for a service, then reversed their decision without the knowledge of the patient. Another scenario is one where the patient is wrongfully charged for a service that should have been covered. While some viral stories have encouraged patients to follow due process and file claims with their insurance companies for services that should have been covered, not all patients know they can appeal their insurer’s decision.

A recent Kaiser Family Foundation report looked at data on claim denials and appeals from the Centers for Medicare and Medicaid Services. Among other findings, the report showed that consumers rarely appeal claims that have been denied. In 2017, 121 major health insurance issuers denied a total of more than 42 million claims. Consumers appealed less than 200,000 (0.05%) of these denials. Although consumers have the right to bypass their insurer’s internal appeals process and go directly to an external review, this happens in fewer than 1 in 11,000 denied claims (0.009%).

Here’s the good news: appealing a denied medical claim is worth it, and it is your patient right to do so. A recent report by the California Chronic Care Coalition, “Standing Up For Your Rights Creates Results,” showed that the California Department of Managed Health Care reversed or overturned 61% of health plan decisions in 2017. This finding shows that consumers who know their rights and appeal denial can make a change.

Earlier this year, UnitedHealth Group lost a class-action suit filed by 50,000 patients because one of its arms, United Behavioral Health, denied coverage for mental and behavioral health issues. This major success for patient advocates shows the value in fighting back.

Learn more about becoming your own best advocate and filing a claim with your insurer by clicking on the “File a Complaint” link on our website.

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