Insurers often reverse claims denial, GAO says

A new report from the Government Accountability Office found that although insurers frequently deny claims due to billing errors, missing information or judgments on whether the care or service is appropriate, as many as 50 percent of some appeals prompt insurers to reverse their decisions, reports ABC News.

The GAO reviewed data available on denials of applications for enrollment and coverage for medical services from 459 insurers operating in the individual market between January and March 2010. It issued the report at the request of Congress, which wanted to better understand the issue as part of the healthcare overhaul it passed last year, according to the report.

Among its noteworthy findings, the GAO determined that as many as 50 percent of appeals to insurers in Maryland in 2009 led to coverage decision reversals and 48 percent of appeals to insurers in Ohio led to reversals last year. The GAO also cited an AHIP report that studied 37 state external review programs a few years ago and found that about 40 percent of external appeals led to the reversal of a claim denial.

However, the statistics are based on cases appealed, and only a small portion of denials are challenged, says John Dicken, a GAO healthcare director.

To learn more:
- read the ABC News story
- access the GAO report

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