Out-of-Network Claims Denied at Much Higher Rates: What This Means for Your Appeal
By Tatiana Kadetskaya, Appeal Templates LLC
Helping consumers fight unfair health insurance denials with professional, ready-to-use appeal letter templates.
Out-of-Network Claim Denial Rates Are Surging — And Patients Are Paying the Price
According to recent data from the Kaiser Family Foundation (KFF), out-of-network claims had a staggering 37% denial rate in 2023, compared with only 19% for in-network claims.
That means out-of-network claims are almost twice as likely to be denied.
For many patients, the difference between in-network and out-of-network is not a matter of choice. Emergencies happen. Specialists are booked months out. Geographic barriers exist. Yet insurers routinely deny these claims based solely on network status — even when the care was medically necessary, urgent, or unavoidable.
But here’s the part most people don’t know:
You absolutely have the right to appeal an out-of-network denial — and many are successfully overturned.
In this article, we’ll break down why out-of-network claim denial rates are so high, what these denials really mean, and how you can use your rights under federal law to file a strong appeal.
We will also show you how to use our Free Appeal Guide as a first step and our $29 Out-of-Network Appeal Template if you want a polished, ready-to-send appeal letter.
Why Are Out-of-Network Claims Denied More Often?
The KFF findings confirm what many consumers already know: insurers aggressively deny out-of-network claims, even when circumstances were outside the patient’s control.
Common reasons for high out-of-network denial rates include:
✔️ 1. Insurer Cost-Saving Tactics
Out-of-network providers don’t have pre-negotiated rates with insurers, which means the insurer would have to pay more.
Denying the claim is the insurer’s easiest way to cut costs.
✔️ 2. Automatic/Algorithmic Denials
Many plans rely on automated systems that trigger near-instant denials when a provider is not in network.
These denials often completely ignore:
Geographic limitations
Emergency conditions
Referral needs
Lack of in-network options
✔️ 3. Billing & Coding Errors
Out-of-network claims often involve:
Wrong plan billed
Incorrect taxonomy codes
Provider billing under a secondary NPI
Emergency services misclassified as elective
A simple billing mistake can trigger an out-of-network denial — but it can be fixed through appeal.
✔️ 4. Prior Authorization Issues
Insurers frequently deny claims for:
“No prior authorization”
“Out-of-network authorization denied”
Even when the patient or doctor attempted to obtain the authorization or when no in-network provider existed.
✔️ 5. No In-Network Option but Still Denied
Even if no in-network specialist exists within 50–100 miles, insurers may still deny the claim — hoping the patient will not appeal.
This is precisely why out-of-network appeal rates need to increase. Consumers have rights, and most do not use them.
What a High Out-of-Network Claim Denial Rate Means for You
A 37% denial rate does not mean 37% of those claims were invalid. It means insurers are relying heavily on network status as a denial shortcut.
Here is what the KFF data really means for patients:
✔️ 1. Insurers Count on You to Give Up
Fewer than 1% of denied claims are appealed — even though millions are denied each year.
Insurers know most people feel overwhelmed and uncertain of their rights.
✔️ 2. Many Denials Are Reversible
Out-of-network appeals are often overturned because:
The patient had no reasonable alternative
The care was urgent or emergent
The in-network specialist was unavailable
Billing was incorrect
Prior authorization was requested but ignored
A strong appeal letter outlining these facts gives you a real chance of success.
✔️ 3. You Have Federal Protections
Under the Affordable Care Act, insurers must cover emergency care at in-network rates, even when the hospital is out-of-network.
Under ERISA, you have the right to:
A fair internal appeal
A binding external review
A full explanation of the denial
Review of the insurer’s clinical guidelines
These rights give you real leverage — even when your insurer’s initial answer was “no.”
The Most Common Out-of-Network Denial Reasons (and How to Appeal Them)
Below are the top reasons insurers deny out-of-network claims and what they actually mean for your appeal.
❌ Denial Reason #1: “Provider is out-of-network”
Why it gets denied:
Often an automatic denial with zero medical review.
How to appeal:
Demonstrate that:
You had no in-network options
The nearest in-network provider was too far
You were traveling
It was an emergency
❌ Denial Reason #2: “No prior authorization for out-of-network services”
Why it gets denied:
Insurers claim you were required to get approval first.
How to appeal:
Show that:
Authorization was attempted
No in-network provider was available
You could not safely delay care
❌ Denial Reason #3: “Care could have been provided in-network”
Why it gets denied:
This is often false — insurers simply assume without proof.
How to appeal:
Provide evidence of:
In-network provider directory errors
In-network provider wait times
Specialist unavailability
Your physician’s referral
❌ Denial Reason #4: “Not a true emergency”
Why it gets denied:
Insurers re-label emergencies to deny out-of-network care.
How to appeal:
Cite ACA protections that require emergency care to be paid as in-network.
How to Write an Appeal for an Out-of-Network Denial
A strong appeal letter includes:
1. Your identifying information
Name, member ID, claim number, date of service.
2. A clear appeal statement
“I am formally appealing the denial of an out-of-network claim.”
3. Medical justification
Explain urgency, necessity, and lack of alternatives.
4. Legal basis
Reference your rights:
ACA’s in-network emergency protections
ERISA appeal rights (if employer-sponsored plan)
5. Supporting documents
Attach records, referrals, notes, travel logs, prior authorization attempts, and receipts.
This combination is what gets results.
📘 Step 1: Download Your FREE Appeal Guide
If this feels overwhelming, start with the basics.
My Free Appeal Guide explains everything you need to know:
How to read your Explanation of Benefits
Your appeal deadlines
What evidence strengthens your case
How to submit internal and external appeals
Sample language and checklists
👉 Download your FREE Appeal Guide here
📝 Step 2: Get the $29 Out-of-Network Appeal Template
If you need to send an appeal fast — and you want it written professionally — the $29 Out-of-Network Appeal Template is the fastest, most effective option.
You’ll get:
Legal-style wording written by insurance & ERISA professionals
Sections tailored to every major out-of-network denial reason
Emergency-care arguments
Lack-of-in-network options arguments
Prior authorization appeal language
Editable Word format
Fill-in-the-blanks structure for your specific facts
👉 Get the Out-of-Network Appeal Template ($29)
This template helps you speak the insurer’s language — clearly and forcefully.
Final Thoughts: Don’t Let a High Denial Rate Stop You
The KFF data proves one thing:
Out-of-network denials are high, but so is the success rate when you appeal.
Do not give up just because your insurer said “no.”
Here's what to do now:
✔️ Download your FREE Appeal Guide to understand the appeal process
✔️ Use the $29 Out-of-Network Appeal Template to send a professional appeal
✔️ Submit both internal and external appeals if needed
You have rights — and with the right tools, you can fight a denied out-of-network claim and win.
