{"id":3787,"date":"2025-07-08T15:54:13","date_gmt":"2025-07-08T15:54:13","guid":{"rendered":"https:\/\/aomtodayprod.wpenginepowered.com\/?p=3787"},"modified":"2025-07-08T15:54:13","modified_gmt":"2025-07-08T15:54:13","slug":"an-overlooked-factor-increasing-health-insurance-denials","status":"publish","type":"post","link":"https:\/\/www.aom.org\/today\/an-overlooked-factor-increasing-health-insurance-denials\/","title":{"rendered":"An Overlooked Factor Increasing Health Insurance Denials"},"content":{"rendered":"

By Daniel Butcher<\/a><\/p>\n

U.S. law governing health insurance and benefits administration has had an unintended consequence of encouraging insurers and third-party administrators (TPAs) to deny more claims and authorizations.<\/p>\n

Academy of Management Scholar Jeffrey Pfeffer of Stanford University<\/a> said that the remedies for harms caused by improper denials of doctor-recommended medical procedures or medication under the Employee Retirement Income Security Act (ERISA) are limited to recovering money.<\/p>\n

\u201cIf an insurer denies you access to care and you die or are permanently injured by this denial, its only recourse is to recover for the actual money that it should have paid,\u201d Pfeffer said. \u201cBecause of the limited remedies, the base case is denial, and so many prior authorizations and many claims are denied by health insurers or TPAs.<\/p>\n

\u201cIt turns out that if you appeal, in about 60% of the cases, the appeal is actually going to be successful; the problem is, only about 10% or, depending upon the study that you look at, 20% but not very many people ever appeal,\u201d he said. \u201cWhen you get a notice that says, \u2018This medicine has been denied\u2019 or \u2018This procedure has been denied,\u2019 it\u2019s required by law to send you a long form in several languages that tells you what you can do to appeal.<\/p>\n

\u201cOnly about 10% of people appeal,\u201d he said, \u201cbut if you do appeal, you will, in fact, have a good chance to be successful.\u201d<\/p>\n

The appeals process is complicated, discouraging many people with legitimate claims that were denied from appealing. In addition, poor and working-class people may be less likely to have the time to appeal.<\/p>\n

\u201cHealth insurance executives say to themselves, \u2018Who\u2019s likely to appeal? \u2019Who\u2019s likely to appeal are people who have time and who have the social capital and resources to appeal, so this mass denial of claims and denial of authorization adversely affects less educated, less wealthy people and underrepresented minorities,\u201d Pfeffer said.<\/p>\n

\u201cThis is one of the reasons why the U.S. healthcare system has such enormously unequal outcomes, because your access depends upon your social capital and your time and willingness to fight with these insurance companies,\u201d he said.<\/p>\n","protected":false},"excerpt":{"rendered":"

By Daniel Butcher U.S. law governing health insurance and benefits administration has had an unintended consequence of encouraging insurers and third-party administrators (TPAs) to deny more claims and authorizations. Academy of Management Scholar Jeffrey Pfeffer of Stanford University said that the remedies for harms caused by improper denials of doctor-recommended medical procedures or medication under […]<\/p>\n","protected":false},"author":4,"featured_media":4243,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[74,76,78,46],"tags":[],"sp_smart_badges":[],"ppma_author":[70],"class_list":["post-3787","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-hr","category-performance","category-policy","category-well-being"],"acf":[],"yoast_head":"\nAn Overlooked Factor Increasing Health Insurance Denials - Academy of Management Today<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.aom.org\/today\/an-overlooked-factor-increasing-health-insurance-denials\/\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Daniel Butcher\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"2 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/www.aom.org\\\/today\\\/an-overlooked-factor-increasing-health-insurance-denials\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.aom.org\\\/today\\\/an-overlooked-factor-increasing-health-insurance-denials\\\/\"},\"author\":{\"name\":\"Daniel Butcher\",\"@id\":\"https:\\\/\\\/www.aom.org\\\/today\\\/#\\\/schema\\\/person\\\/d1297a59039d9ca7bac9d9f0952e508c\"},\"headline\":\"An Overlooked Factor Increasing Health Insurance Denials\",\"datePublished\":\"2025-07-08T15:54:13+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/www.aom.org\\\/today\\\/an-overlooked-factor-increasing-health-insurance-denials\\\/\"},\"wordCount\":365,\"commentCount\":0,\"image\":{\"@id\":\"https:\\\/\\\/www.aom.org\\\/today\\\/an-overlooked-factor-increasing-health-insurance-denials\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/www.aom.org\\\/today\\\/wp-content\\\/uploads\\\/2025\\\/04\\\/health-insurers_benefits-administration_claim-denied_shutterstock_2269069015-scaled.jpg\",\"articleSection\":[\"HR\",\"PERFORMANCE\",\"POLICY\",\"WELL-BEING\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/www.aom.org\\\/today\\\/an-overlooked-factor-increasing-health-insurance-denials\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/www.aom.org\\\/today\\\/an-overlooked-factor-increasing-health-insurance-denials\\\/\",\"url\":\"https:\\\/\\\/www.aom.org\\\/today\\\/an-overlooked-factor-increasing-health-insurance-denials\\\/\",\"name\":\"An Overlooked Factor Increasing Health Insurance Denials - 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Academy of Management Scholar Jeffrey Pfeffer of Stanford University said that the remedies for harms caused by improper denials of doctor-recommended medical procedures or medication under…","_links":{"self":[{"href":"https:\/\/www.aom.org\/today\/wp-json\/wp\/v2\/posts\/3787","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.aom.org\/today\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.aom.org\/today\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.aom.org\/today\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.aom.org\/today\/wp-json\/wp\/v2\/comments?post=3787"}],"version-history":[{"count":0,"href":"https:\/\/www.aom.org\/today\/wp-json\/wp\/v2\/posts\/3787\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.aom.org\/today\/wp-json\/wp\/v2\/media\/4243"}],"wp:attachment":[{"href":"https:\/\/www.aom.org\/today\/wp-json\/wp\/v2\/media?parent=3787"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.aom.org\/today\/wp-json\/wp\/v2\/categories?post=3787"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.aom.org\/today\/wp-json\/wp\/v2\/tags?post=3787"},{"taxonomy":"sp_smart_badges","embeddable":true,"href":"https:\/\/www.aom.org\/today\/wp-json\/wp\/v2\/sp_smart_badges?post=3787"},{"taxonomy":"author","embeddable":true,"href":"https:\/\/www.aom.org\/today\/wp-json\/wp\/v2\/ppma_author?post=3787"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}