About 75% of those who appeal insurer rejections of healthcare claims, end up receiving an approval of the claim. But that does not mean that of those who did not appeal, 75% would have succeeded. Presumably one difference between those who appeal and those who do not appeal, is that on average those who appeal have stronger cases. Of course there are other differences, like perseverance, and the opportunity cost of the time and energy it takes to appeal.
Those opportunity costs, and the damage to morale whether the claim is appealed or not, are usually not counted among the costs of our healthcare system.
Note also in the case discussed below that claims for treatment of rare diseases are much more likely to be denied than otherwise similar claims for common diseases. You see randomized double-blind clinical trials (RCTs) are unlikely to have been done for treatments for rare diseases for a couple of reasons. One is that it is hard to find enough patients to populate the RCT. Another is that even with an eventually successful treatment, the revenue will not be enough to cover the costs of the RCT. So insurance companies can reject the claims because there is no “evidence” for efficacy–where “evidence’ is defined as the outcome of an RCT. The lesson: if you’re going to acquire a dire illness, make sure it is a common dire illness.
(p. A1) CUMMING, Ga.—After three years of doctors’ visits and $40,000 in medical bills didn’t cure their daughter’s rare condition, April and Justin Beck found a specialist three states away who offered a promising treatment.
They set out before dawn last spring for the nine-hour drive to Arkansas Children’s Hospital in Little Rock, where Dr. Aravindhan Veerapandiyan explained how infusions of antibodies could help Emily, now 9 years old, and her misfiring immune system.
They returned home with an appointment to start the infusions. But the Becks’ insurer, UnitedHealthcare, declined to pay for a treatment it said wasn’t medically necessary.
They decided to fight back. “I really had no idea it was going to be this hard,” April Beck said.
Health insurers process more than five billion payment claims annually, federal figures show. About 850 million are denied, according to (p. A8) calculations by appeals company Claimable, based on data from health-policy nonprofit KFF and the Centers for Medicare and Medicaid Services. Less than 1% of patients appeal.
Few people realize how worthwhile those labors can be: Up to three-quarters of claim appeals are granted, studies show.
Patients who fight denied claims must marshal evidence from medical studies, navigate dense paperwork and spend hours on the phone during what is often one of the most difficult times of their lives. They debate insurers over whether a patient might ever recover from a stroke, or whether an expensive new treatment holds real promise.
. . .
The sense of futility that keeps people from appealing denied claims is part of a current of anger against insurers that surged in December [2024] after the assassination of UnitedHealthcare Chief Executive Officer Brian Thompson.
. . .
In one letter, UnitedHealthcare denied the treatment because the medication wasn’t ordered from an in-network pharmacy. In another, on July 25, [2024] the insurer said the treatment wasn’t medically necessary and hadn’t been proven helpful for Emily’s condition.
“The services are not eligible for coverage because your plan doesn’t cover unproven procedures,” the insurer said.
Rare cases often put patients and insurers in protracted conflict. Some people want experimental treatments that insurers reject because they aren’t thoroughly proven to work. But for patients with rare conditions, the number of cases are so small it’s difficult to widely document a drug’s effects.
. . .
April learned from a Facebook support group for parents of children with PANS/PANDAS about Claimable, which uses artificial intelligence to help patients appeal denials. Claimable was offering to submit claims for PANS/PANDAS patients free of charge.
The Becks on Dec. 6 [2024] sent their appeal to the new denial based on medical necessity by email to UnitedHealthcare, copying Andrew Witty, CEO of its parent company, as well as Georgia’s governor and attorney general. Claimable encouraged them to copy Witty on every interaction.
The package included a letter from the PANS Research Consortium stating that immunoglobulin therapy is widely accepted as standard treatment for kids like Emily and that, as of Nov. 22, 2024, 13 states have made it illegal to impede access to the treatment for people with PANS/PANDAS. The letter cited 25 studies backing the treatment’s efficacy. It was cosigned by physicians from Stanford and the National Institutes of Health.
. . .
Two days before Christmas, a representative from UnitedHealthcare called to say Emily had won her appeal. UnitedHealthcare told the Journal that its medical director decided the infusions would be appropriate as a trial for Emily.
For the full story see:
(Note: ellipses, and bracketed years, added.)
(Note: the online version of the story has the date Feb. 12, 2025, and has the title “Health Insurers Deny 850 Million Claims a Year. The Few Who Appeal Often Win.”)