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Insurers more likely to pay up after appeal

Most denied claims for emergency room visits are eventually paid after a patient appeals, a study finds.
/ Source: Reuters

Want your health insurance company to pay up on a claim? Just appeal any denials, research in California suggests.

A study of two large managed care plans in California showed that 90 percent of all denied claims for emergency room visits were eventually paid after patients appealed the decision.

The review of 405 appeals, to be published in the February issue of the Annals of Emergency Medicine, showed the average cost of a disputed emergency visit was $1,107.

The researchers at Santa Monica, California-based RAND Corporation and the Harvard School of Public Health said the disputes seemed to arise over when a patient should be worried enough to visit an emergency room, as opposed to waiting for a doctor’s appointment.

Federal law requires hospital emergency departments to examine and stabilize everyone who comes in. But health insurance companies do not automatically pay for this often very expensive treatment.

To cover the gap, 47 states, including California, require health plans to pay for emergency services a prudent layperson would think necessary to prevent serious injury -- even if it turns out the patient’s health was not in serious danger.

For instance, patients complaining of chest pains should be reimbursed for emergency room visits even if it turns out they had indigestion.

The researcher said there is disagreement over what is prudent that causes the insurance companies to at first deny claims. But even insurers cannot agree what “prudent” means, said RAND’s Carole Roan Gresenz, who worked on the study -- so it pays to appeal.