Payor Denials Overturned in 39-59% of Appeals, GAO Finds

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In a survey of payors' claims denials in six states, 39-59 percent of the denials were reversed on appeal, according to a report by the Government Accountability Office.

In comparison, the GAO noted that a similar study by an insurance company trade association found about 40 percent of appeals were reversed after entering independent, external review.

The GAO noted that the rate of the initial denials also varied widely, with California plans rejecting about 24 percent of claims and Ohio insurers rejecting 11 percent of claims in 2009, but part of the variation was due to different criteria for what constituted a denial.

The AMA, which began surveying insurers' claims handling in 2008, found an average denial rate of 4 percent in claims data for major insurers from two months in 2010, the GAO reported.

In a survey of denials of applications for new policies, the report found that 19 percent of such applications were rejected but that rate varied widely, too.

Read the GAO report on claims denials.

Read more coverage of claims denials:

- Illinois Blue Cross Blue Shield Will Pay $25M to Settle Allegations of Denying Children Coverage, Shifting Costs to Medicaid

- As Denials Rise, Hospitals Working Harder to Fend Off RACs

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