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.