What Are Your Options When Commercial Health Insurance Claim Denials Are On The Rise

The experts are predicting a rise in commercial health insurance claim denials. These denials end up costing hospitals and clinics quite a bit of money, as they must pay their billing employees through every step of the collection process. Once those unpaid claims have reached the end of their appeals, the medical facility has two choices – they can either “eat” the cost of the services rendered or bill the patient. Neither is satisfactory, as the former leads to financial insolvency and the latter alienates the patient. In order to keep your hospital on good financial footing, you need to understand how the Federal ERISA process can help.  

Claim Denials Are On the Rise

According to an article published on June 27, 2017, health insurance claim denials end up costing hospitals $262 million dollars every year. This particular study conducted by Change Healthcare, a Tennessee-based healthcare company that specializes in revenue cycles, determined that the initial percentage of claim denials currently sits at 9%. While this doesn’t sound like much, that 9% consists of around $5 million dollars worth of unpaid claims. This really puts the amounts that hospitals are dealing with in perspective.

Usually, around 63% of those initial claim denials end up getting paid, leaving 1.85 million dollars left uncollected. Now imagine doing that much business weekly. (This is just an estimate projected for a large hospital system.) In a month, that’s $7.4 million dollars. That hospital system is losing money constantly, and over time, as you can see, that adds up quickly. That money needs to go towards the costs of equipment, personnel salaries, and everything else that a hospital must have in order to run efficiently.

On top of this, the costs of collecting those funds need to be tallied in. The average claim costs $118 to collect. This amount includes the time spent on billing employees, computer costs, and everything else. As you can imagine, this adds up quickly as well. It’s no wonder that hospitals end up going out of business and smaller practices are swallowed up by larger ones. The debts that they hold can quickly spiral out of control.

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How Claim Denials Work

The best thing to do is to avoid these claim denials. Many are sent back by the commercial health insurance company because the amounts are wrong, they are miscoded, or proper approvals weren’t requested and received. When the health insurance company sends back an unpaid claim, they’ll explain why. Your billing employees will need to check on this reason and find a way to correct it before resubmitting the claim.

At this point, the clinic has their billing employees send in an appeal to the health insurance company. According to current laws, there are three of these appeals available at the state-level.  The insurance company then goes over the newly appealed claim denials and comes up with a new judgment. In some cases, the claim is paid. This makes everyone involved happy. The hospital no longer has to worry about that unpaid claim and they under with more money in their bank account.  In other cases, the insurance company might just pay a portion of the claim. This is called an underpaid claim. The reasons for these depend on the allowed amounts and any preapprovals – basically the same as the ones from the first round of claim denials.

On top of this, the insurance company could also keep refusing the claim outright. As we already stated, the hospital or clinic can go through three rounds of these appeals, even if the claim is underpaid. The collections process allows for this. Every time that the claim is sent back for an appeal, the odds that it will get paid go down. In some cases, the claim is partially paid and then partially paid again, leaving a balance by the end of the appeals process. Each time this happens, it costs the hospital more money and creates additional work for the billing employees. This is problematic since as we explained, over 30% of them end up going unpaid.

When Claims Go Uncollected

After the three state-level appeals process is completed and the claim denials are still in place, your hospital or clinic has a choice. That money usually ends up going uncollected. It goes to your accountant’s office  where it ends up in what we call a “debt bucket.” This is a list of permanent debts on a balance sheet. The medical facility needs to make even more money to make up for this growing list of debts. Since hospitals and clinics have bills to pay so that they can stay open, this list of debts can be extremely problematic. The reason why most hospitals go bankrupt and close their doors is due to them.

Thankfully, there is a solution to getting those claim denials paid. This involves the Federal ERISA process. While many hospital administrators have heard of it, they aren’t sure about how to even begin using it.

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The Solution: Federal ERISA Appeals

A Federal ERISA appeal can be filed on all of those unpaid or underpaid claim denials. The problem with this is that many of these hospital administrators aren’t sure of the process. As you can imagine, this federal process is quite complex, meaning that many billing departments don’t know how to work through it. They aren’t taught this in schools. Plus, many of the employees in those billing departments are busy either with sending out current bills or wading through state-level appeals. They just don’t have to time to figure out Federal ERISA appeals. This means that in most cases, those claim denials are written off and add to an already growing pile of debt.

What is ERISA? It stands for Employee Retirement Income Security Act. It was enacted back in the 1970s and was initially designed to protect employee retirement plans. Over time, it’s become a federal law that protects self-funded healthcare plans as well.

Essentially, the Federal ERISA appeals process is designed to get your hospital the money that it’s owed by those commercial insurance companies. Using it requires the use of a specialized billing process. It all starts with your accounting personnel. Rather than having them place your money in a debt bucket, call in a specialist. Take those claims and place them in a file.  Then call in an expert, such as ERISA Recovery. We’ll need a few things from you, including that list of claim denials and some other information. We can take it from there and will file those Federal ERISA claims for you. On top of this, we have a guarantee in place stating that we’ll recover at least one million dollars in denied claims for you within 12 months. We also don’t charge anything up front.


Is your hospital or clinic burdened with commercial health insurance claim denials? You don’t want your hospital to end up going bankrupt or shutting down – not when there’s money out there that you can still collect. This is why you need to contact ERISA Recovery today. You can reach us at (972) 331-4140 or by filling out the contact form on our website. It’s time for you to move forward and take control of your hospital’s financial future!