The Complex World of Appealing Denied Insurance Claims 

By Consumers for Quality Care, on September 20, 2023

Health care reporter Cheryl Clark recently embarked on a complex mission to create a step-by-step guide on how to navigate and appeal denied insurance claims, sharing her findings with ProPublica.

Clark interviewed over 50 health insurance experts, consumers, lawyers, doctors, and consumer advocates and came to the startling conclusion that there is no simple way to appeal a denied claim. Instead, from her research and interviews she revealed just how hard insurance companies work to deny patient claims. A Kaiser Family Foundation report from earlier this year found less than two-tenths of 1 percent of consumers in Affordable Care Act plans even attempted to appeal denied claims in 2021.

A main issue at the root of the problem is the many kinds of insurance plans and the complex appeal process for each. Each type of health insurance plan comes with its own unique policies and procedures for appealing a denied claim. For example, employer-provided “self-funded plans” and “fully-funded plans” each have their own appeals process, as do Medicaid, Medicare, and state assistance programs. 

Clark even sought the advice of an attorney in San Diego, Jack Dailey, who works with the California Health Consumer Alliance. This group provides assistance to consumers who are struggling to maintain health coverage. Dailey’s solution ended up being a 7-page single-spaced document highlighting the appeals process for just one type of insurance program, Medi-Cal. 

Health care attorney Domna Antoniadis is part of a nonprofit organization called Access to Care, which assists and educates consumers on health insurance rights. She stated, “The appeals process is not always handled properly by the plans, which is why consumers need to report and complain to their relevant government regulators when they believe they’ve been unfairly denied. That’s integral to changing the system.”

Another recommendation that Antoniadis offered for navigating these appeals processes is to read and fully understand your insurance company’s policies. This policy document could be upwards of 100 pages, but it will provide more guidance than even the best short summaries. In addition, denial letters should be required to include detailed steps to appeal the claim.

Another option is to reach out to your doctor. Sometimes a claim is rejected due to a coding error that can be fixed quickly. CQC is deeply concerned with the many hurdles and the complex systems consumers must navigate to appeal denied insurance claims. We urge insurance companies to simplify the appeals process and urge all consumers to know their rights. When a health insurance claim is denied, they can – and should – use the appeals process to avoid paying unwarranted medical bills.