The Recent Surge of Medical Claim Denials and Their Fallout

Numbers don’t lie: Denials are increasing. From the use of Artificial Intelligence in claims processing to IROs rejecting more than half of medical, mental health, and surgical claims coming their way, claims are being denied at a greater rate. Meanwhile, the “why” isn’t the only thing to examine. The repercussions of these denials matter just as much – if not more. Plan administrators are being sued for fiduciary breach and external appeals are surging. Plans are in the media and political spotlight. Stop-loss carriers are deferring to initial decisions to deny in support of their own denials – even after plan decisions are ultimately overturned. The result? Claims decisions, adverse benefit determinations and appeals represent a greater source of risk and liability than ever before. Join The Phia Group as they examine the statistics, the reasons behind these numbers, the fallout, and best practices you need to know.