Pennsylvania program helps overturn 50% of health insurance denials in first year, new data shows

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A state program designed to help Pennsylvanians fight health insurance denials was successful in overturning decisions and reinstating coverage in about half of all cases, according to new data released Wednesday.

Since its launch one year ago, the state Insurance Department’s Independent External Review program has processed 517 appeal submissions from residents across the Commonwealth.

In 259 cases, expert reviewers determined that insurers wrongly denied or limited coverage for medical care. Under program rules, insurers must reinstate or apply coverage for pending procedures, medications and health visits, or retroactively for patients who’ve already been billed for the full cost of care.

“[The Pennsylvania Insurance Department] is glad to see more Pennsylvanians taking advantage of their rights to appeal health insurance claim denials to get their claims rightfully paid, where appropriate,” Commissioner Michael Humphreys said in a statement.

National reports show that insurance denials are on the rise. Nearly one in five people surveyed nationally by health policy research institute KFF in 2023 said they had a health insurance claim denied in the past year.

However, information about how often individual insurance companies deny coverage, and how many cases are appealed and overturned, is scarce and not publicly reported most of the time.

Insurance denials can lead to delays in care and medical debt. State officials estimate that 1 million people in Pennsylvania have some medical debt from unpaid bills and other charges.

In Pennsylvania, residents can file an appeal with the state’s Independent External Review program after they have already completed an internal appeals process with their health insurer.

If they are still denied coverage, people can then submit their case to the state review process, where independent, third-party reviewers analyze individual claims and give a final determination on whether the insurer’s denial was valid or if it must be overturned.

The review program is open to people who have health insurance through a state health plan, the Affordable Care Act Marketplace and other commercial insurance, including employer-sponsored plans offered at private companies, nonprofits and organizations.

People who get insurance from their employer through self-funded plans, in which the employer or company pays health claims directly rather than through the insurance company, are excluded from using the state review program.