The Kaiser Family Foundation’s recent analysis of coverage appeals sheds light on the abundance of coverage denials that go unchallenged. This analysis revealed that only about 0.5 percent of coverage denials are appealed by consumers. This is alarming, as about half of appeals result in a coverage denial being overturned in favor of the consumer. Some states, like California, help facilitate the appeals process by informing patients in writing about the appeals process. However, not all plans have been complying with that requirement, as the California Department of Managed Health Care fined an insurer $2.8 million for failing to properly inform enrollees about their appeal rights. While such a small percentage of claims are appealed, many patients are likely not receiving coverage for services that they should be eligible for. Insurers benefit from this by spending less on medical services for enrollees and retaining a greater share of premiums as profit.
Last Updated on May 14, 2020 by Aimed Alliance
