What should you do if your health care claim has been denied?

Many Americans who expect insurers to cover their treatments or procedures end up being denied vital care. 

Insurers deny between 10% and 20% of health care claims, according to a 2023 ProPublica report, although government data is limited. Meanwhile, 1 in 5 adults had a claim denied between 2022 and 2023, according to a survey by KFF, a nonprofit health information organization.

Americans, many of whom harbor long-simmering anger over our health care system, vocalized their pent-up frustrations on social media after UnitedHealthcare CEO Brian Thompson was fatally shot in December. Twenty-six-year-old Luigi Mangione was indicted in Thompson’s slaying and faces multiple federal charges. 

Health insurers can deny coverage if they decide that a treatment or procedure is not medically necessary, prior authorization was required or a physician isn’t in the insurer’s network, among other reasons. 

“The health insurance market is run by these large, publicly traded companies that depend on quarterly profits, because it all comes down to the money. We see it over and over again that care gets denied because companies are trying to cut costs,” said Rob Gianelli, a Los Angeles-based insurance attorney. 

It can be tough for patients to fight a denied claim on their own. “If it’s a claim of any consequence, there’s really little they can do to get a result outside of hiring a lawyer,” Gianelli said.

Under the Affordable Care Act, you are entitled to an internal review if you purchased your health insurance through the ACA marketplace or if you have an employer-sponsored plan, along with an external review if you’re not satisfied with the decision, said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

So here are the steps you can take: First file an internal appeal with your insurer, which you have to do within 180 days of receiving a denial notice. Unfortunately, this happens very rarely. HealthCare.gov consumers appealed less than two-tenths of 1% of denied in-network claims in 2021, according to KFF. Insurers upheld 59% of denials that were appealed. 

“While many times insurers do uphold those denials, it’s just really telling how little consumers know their rights and their ability to actually do that,” said Mona Shah, the senior director of policy and strategy at Community Catalyst, a consumer health advocacy organization. 

If your insurer maintains its rejection, you can then try appealing your claim through an external review process. You typically have a set timeframe to file an external appeal after your insurer has made its final decision. 

Your insurance company’s Explanation of Benefits or the final denial you receive from an internal appeal should tell you which organization handles your external review and where you can contact that group. 

“It can often be worth it to pursue an appeal. In doing so, [patients] should work very closely with their treating provider. Providers are often quite familiar with this process,” Corlette said. 

Some states, like Alabama, rely on the federal government’s Department of Health and Human Services to oversee the external review process. 

Other states, like California, have their own programs that will conduct an independent medical review depending on the type of insurance you have. This does not apply to those with private employer-provided group insurance; however, those plans typically still have provisions that allow you to file an external appeal outside of state agencies, Gianelli said. 

California contracts with firms that have doctors in given specialties. The doctor will review the claim and decide whether the insurance company’s judgment on medical necessity is correct, Gianelli said. If it’s incorrect, the insurance company will have to reverse its decision. 

But Gianelli said reviewing doctors will sometimes make incorrect assessments. If the decision from the external review upholds the insurer’s denial, then the insured patient has the right to sue, which is where lawyers like Gianelli come in. 

Other states have launched their own independent review programs in recent years, like Pennsylvania. You can now request a review from the state if your insurance claim has been denied. You can apply if you have insurance provided by your employer or if you purchased it from the state’s health insurance marketplace, called Pennie, or directly from an insurance company.

Many states also have Consumer Assistance Programs that will help patients navigate insurance issues via phone, mail, email or walk-in location. The Centers for Medicare and Medicaid Services has a directory that will allow you to see the resources your state offers.

If you haven’t been billed yet by your provider, and you expect to be charged a large amount, don’t panic because the bill could still be canceled or reduced, said Ruth Lande, vice president of provider relations at Undue Medical Debt. 

But if you do end up being billed an exorbitant sum and accumulate medical debt, Undue Medical Debt has a guide that could help you manage your obligations. For example, the guide advises not paying with credit cards or loans, which can swell your debt. It also suggests telling the hospital or bill collector that you simply can’t afford the cost, since they may be able and willing to work with you on it.

You’d be far from alone in doing that. “Don’t feel shame about it,” Lande said.