Up to Half of Insurance Claims Appeals Are Successful, GAO Finds

As many as half of all health insurance claim rejection appeals are successful, according to a Government Accountability Office report that studied insurer rejection rates, the AP/Washington Post reports.

The report, which was requested by Congress, collected data from several states and reports conducted by other agencies.

The report states that insurers often deny claims because of errors in billing, judgments on whether the service is necessary or appropriate, or missing information. Further, it found that U.S. residents often incorrectly fill out codes on claims submitted by their physicians and end up paying bills for which they are not responsible.

However, the report found that appeals to such claim denials often are successful. For example, 50% of appeals to insurers in Maryland in 2009 led to decision reversals and 48% of appeals to Ohio insurers in 2010 led to decision reversals.

In addition, the report states that third-party appeals also are reasonably successful. According to a report from America's Health Insurance Plans that examined 37 external review programs, 40% of external appeals led to decision reversals.

John Dicken, a GAO health care director, noted that only a small portion of denials are challenged (AP/Washington Post, 3/16).