April 26, 2011 Columns

Bottom Line: It Pays to Appeal Claim Denials

Historically when an insurance company denied a claim, some providers and consumers felt that this meant they had no further recourse. As a result, those providers provided a service for which they weren't paid and the consumers had to pay privately for the service, which in turn may have prevented them from continuing with those services. With increased education, however, more people are appealing the denials. According to a recent report by the Government Accountability Office (GAO), the results indicate a success rate of nearly 40% with appeals  (GAO-11-268 Private Health Insurance–Data on Application and Coverage Denials March 2011). The GAO reported on both application (enrollment) and service coverage denials. The information on coverage denials is of particular interest for speech-language pathologists and audiologists as it is useful in preparation of appeals. The GAO report addressed findings in several areas:

  • Variability. Six states—California, Connecticut, Florida, Maryland, New York, and Ohio—and numerous insurers were included in this report. The percentage of overturned coverage denials spanned a range both among the states and the insurers.
  • Type. Just as the most common errors that taxpayers make in completing tax forms are forgetting to sign the return and transposing numbers, so too the most common errors in filing insurance claims involve missing, incomplete, or incorrectly entered information. Regarding eligibility, this may include failure to get preauthorization prior to providing a service (if this is required) or initiating service prior to the date that coverage was initiated or after coverage was terminated
  • Coverage. Insurers may deny coverage before or after the service has been provided.  Claims denied as a result of judgments about the appropriateness of the service can be overturned with appropriate documentation. Appeals for claims can be reviewed internally by the insurer, but may also be requested and reviewed by an independent reviewer. Data from four of the six states showed that between 39% and 59% of internal appeals preserved the coverage denial. In the current study, between 23% and 54% of externally reviewed appeals were reversed or revised. The reversals occurred because either the consumer or the provider submitted additional information (e.g., medical records).

Given the information from the GAO report, SLPs and audiologists, as well as their clients, should feel encouraged about filing appeals, with reasonable expectation for successful outcomes.

Laurie Alban Havens, MA, CCC-SLP, director of private health plans and Medicaid advocacy, can be reached at lalbanhavens@asha.org.

cite as: Havens, L. A. (2011, April 26). Bottom Line: It Pays to Appeal Claim Denials. The ASHA Leader.


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