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> Denying claims generally doesn't improve health insurance company profits. If this is true, why do several of the larger companies deny so many claims? I can

• nradov 2y ago
  As I wrote above, health insurers ultimately have to answer to their customers. Those are mainly employers, especially large companies with self-funded health plans. Those employers are constantly pressing insurers to cut medical expenses, and so sometimes insurers tighten coverage rules on their standard health plans in order to close more sales. Payers do make errors in claims processing and improperly deny some claims, but the majority of denials are due to errors on the provider side. They often fail to code claims correctly or don't obtain required prior authorization or don't follow step therapy or fail to attach enough clinical documentation to establish medical necessity. Many of those initial denials are later approved once the provider corrects the errors and resubmits the claim. But in fairness to the providers, it's hard to get everything right the first time because every payer has different rules and they're sometimes ambiguous.