Pennsylvania program overturns 50% of health insurance denials, new data shows

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.