QUARTERLY NEWSLETTER | FALL 2023 – #50
Supporting Patients in Appealing Claim Denials Is Worth the Effort By Joy Stephenson-Laws, Managing Partner Providers are now reaching some level of “new normal” with the pandemic becoming more of an endemic. They can identify challenges to improve their margins as quickly as possible.
Many are seeing a concerning picture. Before the pandemic literally threw providers into operational survival mode, I wrote about the importance of partnering with patients to reduce pre-certification denials. In that blog, I talked
about how payor-denied claims continue to top the list of threats to a healthcare provider’s financial wellbeing and how working with patients to avoid pre-certification and pre-authorization denials can positively impact a provider’s bottom line. And while this effort is indeed important, it is usually limited to what a provider can do before medically necessary services are billed. Just as critical to protecting a provider’s financial health, and something that data indicate is greatly underutilized, is working with patients to appeal
insurance denials after a service has been submitted for reimbursement. Some hospitals have been reporting an increase in denial rates with over a third reporting rates approaching 10 percent. Given these denial rates, what is quite surprising is that only about 0.2 percent of medical insurance denial claims are appealed by patients. It also is counterintuitive given that, by some estimates, around 50 percent of these appeals are eventually successful. This success rate may even be higher for self-insured employer plans.