Appealing Solutions Video Series: Medical Claim Appeal Success Rates - Why You Should Challenge Your Health Insurance Denial

Health insurance claim denials can be frustrating and overwhelming. Many policyholders, upon receiving a denial, assume that the insurance company’s decision is final. However, data shows that appealing a denial significantly increases the likelihood of getting the claim approved. Unfortunately, very few individuals take advantage of this opportunity.

Understanding Health Insurance Denial Rates: Medicare vs. Private Insurance

The Reality of Claim Denials

Insurance claim denials are more common than many people realize. According to KFF (2023), in 2021, less than 0.2% of denied in-network claims in HealthCare.gov plans were appealed. This means that the vast majority of denied claims go unchallenged, leaving individuals without the coverage they may rightfully deserve.

Many policyholders may be unaware of their right to appeal, feel discouraged by the complexity of the process, or assume that appealing will not make a difference. However, the data tells a different story.

Medical Claim Appeals Can Be Highly Successful

For those who do take the time to appeal, the results are often in their favor. A study by the American Medical Association (2023) found that in 2022, over 80% of prior authorization appeals resulted in the insurance company overturning its initial denial. This means that when policyholders and healthcare providers push back against a denial, they have a strong chance of success.

These findings highlight an essential fact: insurance companies sometimes deny claims incorrectly or without adequate justification. Appeals serve as an important mechanism to correct these errors and ensure patients receive the medical coverage they need.

Why Aren’t More People Appealing?

Despite the high success rate, the vast majority of denied claims remain unchallenged. Several reasons contribute to this trend:

🔹 Lack of Awareness: Many individuals do not realize they have the right to appeal a denial.

🔹 The Process Seems Overwhelming: The appeals process involves gathering medical records, writing appeal letters, and understanding insurance policies—tasks that can be intimidating.

🔹 Time and Effort: Patients managing health issues may not have the time or energy to navigate the appeals process on their own.

How to Successfully Appeal a Denied Claim

If you’ve received a denial, don’t give up! Here’s how you can improve your chances of a successful medical claim appeal:

✅ Understand the Reason for Denial: Carefully read the denial letter and Explanation of Benefits (EOB).

✅ Gather Supporting Documents: Obtain letters from your doctor, medical records, and relevant policy information.

✅ Write a Strong Appeal Letter: Clearly explain why the denial should be overturned, citing medical necessity and policy terms.

✅ Submit and Follow Up: Keep track of deadlines and be persistent in following up with the insurance company.

Need Help with Your Appeal? We’re Here for You!

At Appealing Solutions Medical Advocacy Partners, we specialize in helping individuals navigate the insurance appeals process. Our team provides expert guidance, professionally written appeal letters, and step-by-step support to increase your chances of success.

📞 Contact us today at (303) 503-7747

📧 Email: info@asmapartners.com

🌐 Visit www.asmapartners.com to schedule your FREE consultation.

Don’t let a denial stand between you and the care you need. Appeal today—it’s worth it!

References:

American Medical Association. (2023). Health insurer policies force unnecessary delays, errors, and denials for necessary care. Retrieved from https://www.ama-assn.org

Kaiser Family Foundation. (2023). Claims denials and appeals in ACA marketplace plans. Retrieved from https://www.kff.org