It’s the common drumbeat of health care in the US: medical insurance denials, often for essential and even life-saving treatment. Statistically, 19% of in-network and 37% of out-of-network medical claims were denied for HealthCare.gov marketplace plans, averaging a 20% denial rate overall. It’s a constant source of frustration for patients and doctors alike.
The basic advice when you’ve had a medical insurance denial is: APPEAL, APPEAL, APPEAL. Many times the initial refusal is generated by an algorithm rather than a human being; in other cases, the reviewer has no medical credentials. Doctors have an unfortuate level of experience with appeals; see if you doctor will work with you to get the request approved. In many cases it is a matter of supplying adequate documentation. 75% of appeals are successful, so go for it!
AI Helps With Appeals
Recognizing that medical insurance companies often use AI algorithms to deny your claim, one company has designed an AI system to help with your appeal. NBS News recently did a story on Claimable, a company founded by a team of healthcare and insurance insiders, data scientists and technologists who are committed to challenging the 850 million denied U.S. health claims each year uisng the same technology insurance companies do to minimize expenses.
AI Helps Appeal Denied Medical Insurance Claims
Third-Party Appeals Often Successful
When a health insurer refuses to pay for your treatment, you may have the right to have the denial reviewed — and potentially overturned — by an independent provider.
PROPUBLICA: Little-Known Appeal Could Force Your Insurer to Pay for Lifesaving Care.
Help From the Government
Many states have a Consumer Assistance Program (CAP) that is part of their insurance oversight. Especially if other appeals have failed, this may be a good option.
NC Consumer Services Division of the Department of Insurance
