How to Fight Back if Your Health Insurance Claim is Denied

This Op-Ed originally appeared in The Dallas Morning News


As open enrollment season for insurance is ending, patients should be aware of an alarming trend — the escalating rate of health insurance claim denials —and what they can do to advocate for themselves if denied coverage. Over the last year, denials have increased nearly 8%, with 11% of all claims being rejected, according to the American Medical Association. This surge is largely attributed to systemic efforts by insurers to control costs — often at the expense of our most vulnerable patients. As you consider your insurance policy’s options, here is some information you need to know and what to review on your policy.


Many major insurers have deployed automated systems that rely on artificial intelligence to approve or deny claims in huge numbers at once, without oversight by a medical professional. Other barriers to coverage approvals include prior authorization requirements for specific services and “fail first” policies that require patients to try and fail their insurer’s preferred treatments before getting approved for their doctor’s prescribed treatment.


This bureaucratic maze is particularly detrimental for chronic disease patients, who face more denials and rely on regular costly treatments for the rest of their lives. For example, for patients with inflammatory bowel disease, which includes Crohn’s disease and ulcerative colitis, coverage denials and delayed care can lead to hospitalizations and surgery, including colon removal, which may have been avoided with appropriate care.


One IBD patient’s story vividly illustrates the impact of coverage denials. Chris McNaughton, 31, a patient with severe ulcerative colitis, struggled for years to find an effective treatment and manage his debilitating symptoms, which included severe abdominal pain, frequent bloody diarrhea, and significant weight loss. This forced him to leave college and return to his parents’ home. Despite finding an effective treatment recommended by his esteemed Mayo Clinic doctors, his insurance company consistently denied coverage, disregarding his medical team’s advice. Not only did this exacerbate his symptoms, but it also led to additional health problems like ulcers and skin welts. Although his family sued the insurer and eventually reached a settlement, Chris still faces ongoing insurance denials from the same insurer, continuing his cycle of uncertainty and health risks.


What should you do if your claim is denied?

While the appeals process is time-consuming, you can and should always appeal claim denials. Americans file appeals on as few as 0.2% of coverage denials under ACA marketplace plans, but appealing can be worth it. In 2021, according to the Kaiser Family Foundation, more than 2 million prior authorization requests were denied by Medicare Advantage insurers, yet only 11% of these denials were appealed. Importantly, 82% of those few appeals were successful, either fully or partially overturning the original denial.


Here are other tips to keep in mind while navigating the appeals process:

Review your insurance plan

Familiarize yourself with what your insurance policy covers. Your insurer may have specific exclusions and conditions for each type of coverage, so it’s important to read the language for your specific type of coverage denial. Contact your insurer if you have any questions about what is covered.


Follow up on your appeal and thoroughly document every step

Talk to your insurance company early and often throughout the process. Regularly check in on the status of your appeal; take notes with names, dates and details about your conversation; then follow up! Make sure you pick up the phone even from an unfamiliar number if you’re expecting a callback.


Seek support from your allies

Tell your doctor as soon as you receive a denial to keep them informed of your health status. Leverage their experience; they may be able to advise you or even follow up with your insurer on your behalf.


Many patient advocacy organizations offer resources for specific conditions, including support in navigating the insurance process. For IBD patients, the Crohn’s & Colitis Foundation offers a dedicated patient help center and sample appeal letters that doctors can send to insurance companies.



Ask your HR department to remove a copay accumulator

Many chronic disease patients, with conditions like IBD, arthritis, or heart disease, rely on copay assistance from manufacturers and nonprofits to help them save thousands of dollars in deductible and other out-of-pocket costs. But insurers and pharmacy benefit managers are increasingly using copay accumulator programs to prevent this assistance from counting toward a patient’s deductible or out-of-pocket maximum. As a result, patients struggle to afford their critical medications.


Ask your HR department if your insurance plan has a copay accumulator program in place, and if so, ask if they can work with the insurer to remove it.


Be a proponent for change

Getting involved, in ways big and small, can help you feel less alone — and it makes a real difference for the future of patient care. There are many advocacy groups fighting for legislation to protect patients. You can join them, or contact your legislators directly, in supporting proposed measures like the Help Ensure Lower Patient (HELP) Copays Act and the Safe Step Act, both of which would help rein in patient costs and coverage barriers.


Chris McNaughton is now attending law school, with the goal of becoming a health care lawyer. He hopes his education and personal experiences will help other patients.


As you confront the challenges posed by health insurance denials, carefully review your policy, and remember that advocating for yourself and others can help ensure that more coverage decisions are made with the quality of patient care as the true bottom line.


You can make an impact on IBD cures! Please consider making a donation to the Crohn's & Colitis Foundation.