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Patients Often Win When They Appeal Directly

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  • April 24, 2014
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Direct appeals by patients to insurers or state regulators can be successful approximately half the time, depending on where you live, according to recent studies.
Public radio and Kaiser Health News looked at what happens when a patient appeals directly for denied coverage or a claim, and the results average about 50/50. Even before the implementation of the Affordable Care Act (ACA), results were often positive. But the ACA improved patients’ chances by creating national standards, which allow appeals to a payer and, if necessary, a third party.
Capital Public Radio in Sacramento analyzed multiyear data from California and also found that nearly half the time a patient appeals a denied health claim to the state’s regulators, the patient wins.
A 2011 GAO report sampling data from a handful of states before the health law took effect found that patients were successful 39 to 59 percent of the time when they appealed directly to the insurer. When appealing to a third party (such as the state insurance commissioner), patients also were often successful in getting the service in question – winning as many as 54 percent of such decisions in Maryland, for example.

Brad Ericson
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Brad Ericson, MPC, CPC, COSC, is a seasoned healthcare writer and editor. He directed publishing at AAPC for nearly 12 years and worked at Ingenix for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.

No Responses to “Patients Often Win When They Appeal Directly”

  1. Julie, CPC says:

    Patients should be encouraged to take an active roll in health insurance denials. I know of several, recent appeals for ACA plans that have been or are being resolved due to the patient getting involved.