Common Group Health Insurance Claim Problems and How We Solve Them

A man in a suit is talking on a telephone, discussing group health insurance.

Health insurance claim denials are on the rise.

Some 17% of claims were denied, on average, according to a recent KFF study. And since challenging or appealing these denials is costly and time-consuming, many people simply don’t do it.

As group health insurance brokers, we are dedicated to helping our clients navigate the challenges of healthcare claims processing.

But if you’re curious about how we do it or what to keep in mind if you are trying to weave through the maze of health insurance claim processing, here’s what you should keep in mind.

Reasons Why Health Insurers Deny Coverage

Group health insurance can be complicated. When health insurers deny coverage, your employees might be left scratching their heads. Here are a few reasons why this happens.

Paperwork Problems

Let’s say that your healthcare provider’s office submitted a claim for you but used the incorrect middle initial. Or they could also use the wrong billing code. If that happens, the claim could be denied.

Issues with Medical Necessity

Medical necessity involves ensuring proper documentation, complying with accepted medical standards, and effectively communicating the rationale behind the provided care. Comprehensive, clear documentation by healthcare providers is essential to reduce the likelihood of claim denials. Top of Form

The Care Isn’t Covered in the Plan

When providers or patients submit care claims that aren’t included in the insurance plan, your group health insurance provider will review the claim against the terms and policies of the plan. Should the service fall outside of the plan, it’s likely the plan will be denied, causing the patient or provider to be responsible for costs.

To avoid claim denials, you must work with someone like an agent who can walk you through the coverage details in your insurance plan and avoid seeking or providing services that aren’t included. It’s also important to communicate this to your employees. Top of Form

Navigating Group Health Insurance Coverage Confusion

Coverage terms can be confusing, as we just pointed out. Helping your employees navigate coverage confusion more easily starts with assisting them to make informed decisions about healthcare options within a group healthcare plan.

Work with an informed insurance agent, particularly one who is local, to dissect what’s covered and what isn’t. Top of Form

Provider Network Issues

Another risk for claims denial is provider network issues. Provider network issues are common for patients who don’t understand their plan. Seeking care from an in-network provider is a critical first step to avoiding denials. However, insurance companies often provide directories to help you avoid the risk of choosing an out-of-network provider. Top of Form

Failure to Follow Rules

Not meeting the criteria for specified insurance policies can also lead to claims being denied. Following the rules, understanding the insurance policy’s terms and requirements, and submitting claims accurately and on time reduce your risk of claim denial.

Top of Form

Missing Information

Insurance companies review claims for accuracy and completeness before processing payments. Missing or erroneous claim information creates challenges in processing claims efficiently and accurately. Again, healthcare providers and patients must ensure all necessary information and documents are accurately and promptly completed. Top of Form

How We Solve Health Insurance Claim Denials

As a group health insurance broker, we frequently come up against issues with claims. While we are not directly responsible for solving those issues, we work tirelessly to ensure we do everything we can to help you resolve them. Here’s how.

We Use Our Experience

As brokers, we utilize our industry knowledge, expertise, and network to navigate the complexities of health insurance.

We first do this by working alongside your group to understand their needs, budgets, and coverage requirements.

Our comprehensive assessment helps us craft a tailored insurance plan that aligns with your group’s needs.


We educate your group about the intricacies of different insurance plans and clearly explain coverage terms, limitations, and benefits.

We also communicate with the group and insurance carriers to leverage network options properly.

The goal is to optimize coverage and reduce out-of-pocket costs.


Group health insurance brokers in Houston also offer guidance on policy compliance, emphasizing the importance of adhering to policy terms and rules to avoid claim denials.

As brokers, we also act as an advocate for your group. Our team liaises between the group and insurance carriers, offering fair claim resolutions and assisting in appeals.

At times, we can even try to overturn unjustified denials and ensure that legitimate claims are processed correctly.


An educated and experienced health insurance broker is essential to reducing the number of claim denials your group is exposed to.

Mastering The Claims Appeals Process—Easily

Successfully appealing rejected claims involves the following steps:

  • Step 1. Understand the denial reason.
  • Step 2. Collect documentation.
  • Step 3. Review policy terms.
  • Step 4. Follow all appeal procedures.
  • Step 5. Craft a compelling letter.
  • Step 6. Include supporting evidence.
  • Step 7. Seek provider support.
  • Step 8. Be persistent and polite.
  • Step 9. Document everything.

Our team can help with this process quickly.

Get The Help You Need for Healthcare Claims Processing

Not only does PCI help craft your group health insurance coverage plans, but we also work with proactive claim submission. We’re dedicated to giving you smoother and error-free submissions.

Don’t let claims processing get you down.

Work with brokers in Houston who understand the ins and outs of submissions to get the most out of your policy. We’re here to help.

Contact us today to learn more about how we can reduce your claim denials and set your employees up for better healthcare.

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