Health insurance company denied your medical claim? There are ways to get it approved

When his health insurance company denied medical claims for his son’s hospital stay in Chicago, Brandon Kennedy got creative.

“I called my local union, the health department, health branch of the local union,” he said.

Kennedy went to his union’s health trust, which overrode the insurance company’s denial. It saved him tens of thousands of dollars.

Then there’s Jessica Wozniak, of Wheaton, who was diagnosed with stage four colon cancer at 35 years old. When her insurance company denied coverage for Wozniak's treatment, her employer’s HR department helped her get approval.

“Really advocate for yourself and that's what I've done and hopefully that's what other people can see and maybe do for themselves as well,” she told NBC 5 Responds.

But the majority of Americans don’t go to the lengths Kennedy and Wozniak have to get their denied health insurance claims approved.

In fact, a new analysis of ACA Marketplace plans by the Kaiser Family Foundation found less than 1% of denied health insurance claims were appealed in 2003.

And according to an analysis of federal health care data by Value Penguin, of all of the major health insurance companies, those with the highest denial rates include:

1. United Healthcare with a 33% denial rate.
2. Molina Healthcare with a 26% denial rate.
3. Anthem and Medica with a 23% denial rate.
4. Aetna with a 22% denial rate.
5. Cigna with a 21% denial rate.

This data does not include employer-sponsored plans, Medicare, or Medicaid.

Value Penguin also took a look at insurance companies with the lowest claim denial rates. Those include:

1. Avera health plans- 1% denial rate
2. Pacific Source health plans, a non profit, has a 2% denial rate
3. Providence health plan denies 4% of claims
4. Sanford health denies 5% of claims
5. Kaiser Permanente denies 6% of claims

How to get your DENIED health insurance claims APPROVED

Adria Goldman Gross is the founder of Medwise Insurance Advocacy, a group that helps patients appeal denied medical insurance claims.

"If you have a problem with the bill, the first thing you really should do is call the medical provider, call your insurance company, see why they're not paying it," Goldman Gross aid.

Goldman Gross says it's in these situations where it can be helpful to emphasize the worst-case scenario about your health care needs when talking to your insurance company in either a phone call or appeal letter.

"These are the type of things that should be in those letters. I had a case one time where someone needed surgery and it's usually used only for epilepsy, but she had depression. And when we were able to prove that every other step that she took, you know, to try and control this, when we finally said to [them], 'Hey, look, she was even thinking of committing suicide,' they overturned the case," said Goldman Gross.

Goldman Gross said if the insurance appeal process doesn’t help you, she’s seen success with the strategies Brandon Kennedy and Jessica Wozniak used. Ask your union or your company’s HR department to contact the insurance company on your behalf.

If you’re not in a union or don’t work for a company that has an HR department, Goldman Gross said you should go to your state for help.

“The departments are the Department of Insurance, the Attorney General, the Consumer Affairs," Goldman Gross said. "And let me tell you, don't just write to one. I would write to all of them and tell them what's going on and see what they can do.”

You can request an "external review" from the Illinois Department of Insurance if your health insurance claim denial involved medical judgement, experimental treatment and pre-existing conditions.

You can also request a review if your coverage was rescinded - in other words, approved, and then for some reason denied or "clawed back" - as long as non-payment of premiums isn’t a factor.

There's one important caveat: you can only request this official review once you’ve exhausted all appeals with your health insurance company. And you must file your external review request within four months of receiving of final health insurance denial.

But how likely is it that department of insurance is able to help? NBC 5 Responds analyzed the data.

According to the department’s ‘Consumer Health Annual Report’, in 2023- the latest year data was available- the department was able to overturn about 41 percent of the health care denials it reviewed.

But there’s another caveat here. About 75 percent of all the requests for review the department received in the past few years have been rejected because they weren’t eligible.

That can happen if the consumer hasn’t yet exhausted all internal appeals with their health insurance company.

If you still don’t get anywhere and you need to pay the medical bill, call your medical provider’s billing department, and ask to negotiate a lower payment. There’s a trick to this, Goldman Gross explained:

1. See what the Medicare rate is for whatever procedure you were billed for. By law, this information must be posted on medicare.gov. Goldman Gross explained, "Normally an insurance company never pays out more than 160% of whatever that Medicare rate is," Goldman Gross said.
2. Calculate 160% of the Medicare rate for your procedure.
3. Goldman Gross says that’s the negotiated amount you should offer to pay your provider.

For example, Medicare.gov shows Medicare would pay $1,368 for cataract removal surgery. So, multiply $1,368 by 160%. That total is $2,188, so that’s how much you should offer to pay your provider if you’re negotiating down a bill.

Other Avenues To Explore

If the treatment you're seeking involves a costly drug, you could have success by appealing directly to the drug company.

"There are times that people can't afford their medication and I call the drug companies and I have to be honest. I would say as long as they're manufactured in the United States...lot of times they help people, especially when you can't afford it," said Goldman Gross.

 If you have trouble advocating for yourself, consider calling on an elected official.

"If you want to get a rush on it and you're really concerned, I am telling you, I would go to my congressperson. I would call the congressperson, say, 'Hey, look, I need help. Can you please call the departments for me and help me?'" said Goldman Gross.

You can also go to a medical billing advocate for help, but that usually comes with a fee.

NBC 5 Responds reached out to the insurance companies named in this story. As of publication, these are their full responses:

FULL STATEMENT FROM UNITED HEALTHCARE:

“We do not use AI to make coverage decisions.

Across UnitedHealthcare, we ultimately pay 98% of all claims received that are for eligible members, when submitted in a timely manner with complete, non-duplicate information. For the 2% of claims that are not approved, the majority are instances where the services did not meet the benefit criteria established by the plan sponsor, such as the employer, state or Centers for Medicare & Medicaid Services (CMS). Only 0.5% of claims are not approved based on clinical evidence and patient safety. 

Regarding the studies you asked about, the assertion that UnitedHealthcare denies 32% of claims is out of context and misleading. It does not reflect UHC’s overall claims denial rate, as stated above. That figures you are asking about are based on data UHC provided to the Centers for Medicare & Medicaid Services (CMS) for Individual and Family Plans (IFP) in 2022 representing less than 2% of UnitedHealthcare’s total claims. It is important to note there is lack of standardization in the industry regarding claim protocols.

While we use machine learning to gather clinical data and support clinical and administrative professionals throughout the decision-making process, we do not employ AI to issue any clinical determinations. We believe current AI models cannot, and should not, replace human decision-making, and should instead be viewed as a supportive tool for the provider and patient. These tools help surface insights and information based on the latest medical knowledge, patient history, and historical outcomes data. AI never replaces the care provider’s decision but enables it.”

United Healthcare also shared this context about reported claim denials: “There is a lack of industry standardization about reporting denials data, which means some claims might be reported as denied even when there is no impact on a member’s costs or health care.” For example, UnitedHealthcare said “A claim for a routine vaccine where the administrative fee was paid might show up as being denied because the claim also lists the serum for the vaccine, which does not require payment.”

FULL STATEMENT FROM CIGNA:

To be clear – we do not use AI to deny care or claims. You can read more about our approach to AI here: The Cigna Group’s approach to ethical AI practices | Cigna Newsroom. The most frequent cause of avoidable prior authorization denials is submission errors including incomplete information submitted by the physician’s office. When we do not receive sufficient information, we attempt to obtain the missing information from the requesting physician. If our attempts are not successful, regulatory requirements require us to issue a denial.

FULL STATEMENT FROM AETNA:

“Aetna is committed to helping our members receive high quality appropriate care at the right time. We do not use artificial intelligence or algorithms to deny prior authorization requests or claims based on medical necessity and have no plans to implement such a system. We are continually improving our prior authorization processes with the goal of creating a better experience for everyone involved, while preserving the value that prior authorization brings.”