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Consumers usually win when they appeal claim denials


When consumers challenge a healthcare service their insurer denied, they win about half the time, data from California insurance departments show.

The Affordable Care Act allows all consumers to appeal any denied service to a third party, like a state insurance department. Before the reform law, no standard process for appealing an insurer's denial existed, reported Capital Public Radio.

"Insurers get it wrong the first time," Cheryl Fish Parcham of Families USA, told the news outlet. "So if you've been denied a healthcare service, it might be because the plan didn't understand why that service was needed and why it fit their guidelines."

Data from the California Department of Managed Health Care show the consumer appeals from 2006 to 2012 for Kaiser Permanente had an average success rate of 56 percent. Meanwhile, 53 percent of appeals against Anthem Blue Cross were successful and 52 percent of Blue Shield of California's denials were overturned.

But America's Health Insurance Plans says insurers deny only about 3 percent of claims. "Coverage decisions are based on medical evidence," AHIP spokesperson Robert Zirkelbach told Capital Public Radio. "It's the medical evidence that drives coverage decisions, and the more evidence that's available about the appropriateness and effectiveness of a particular drug or treatment or technology, that's what drives what's covered."

An American Medical Association's annual health insurer report card released last year shows insurers are indeed denying fewer claims, dropping from 3.48 percent in 2012 to 1.82 percent in 2013, FierceHealthPayer previously reported.

Meanwhile, Humana last fall faced accusations of repeatedly denying legitimate claims for Medicare-covered services in Minnesota. Attorney General Lori Swanson provided 27 complaints from Humana Medicare Advantage members in Minnesota who alleged the insurer overcharged them or inappropriately denied their claims.

To learn more:
- here's the Capital Public Radio piece

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