According to a report by Capital Public Radio, patients who appeal denied health care services through third parties win their appeal approximately half the time. Under the Affordable Care Act, insured patients have the right to appeal their denial both to their health plan and to an outside reviewer.
Based on data from the California Department of Managed Health Care, between 2006 and 2013, the average success of patient appeals to the largest insurance companies was between 50 and 57 percent.
Although insurance carriers get a lot of criticism for wrongly or purposely improperly denying claims, there are errors that can occur during the process that may also result in a claim being denied. These include billing errors or data entry errors.
Regardless of the reason for the denial, the system can be frustrating and overwhelming for patients, who are likely dealing with their own health issues while appealing their insurance denials.
Meanwhile, the rate of denials appears to vary wildly among insurers. According to a 2011 report by the Government Accountability Office (GAO), denial rates for the first quarter of 2010 were 19 percent, but around 25 percent of insurers had denial rates lower than 16 percent, while another 25 percent had denial rates of higher than 40 percent.
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“Further, the data we reviewed indicated that coverage denials, if appealed, were frequently reversed in the consumer’s favor and that appeals and complaints related to coverage denials sometimes resulted in financial recoveries for consumers,” the report noted.
In other words, although having a claim denied can be incredibly frustrating, policyholders who appeal the denial stand a reasonable chance of having that denial reversed. In cases where lawsuits are filed, consumers may be able to recover punitive damages, depending on the circumstances of their case.