Who Wins and Why? Investigating External Appeal Success and Systemic Financial Equity

Amid the growing cost of healthcare and number of claim denials, the external appeals system remains an understudied component of the healthcare system. Framed through the lens of the financialization of healthcare, this study investigates how systemic structures shape differential outcomes based on plan and case characteristics. Employing a cross-disciplinary approach that integrates legal, health policy, and sociology perspectives, this research examines New York State's external appeal data using a series of progressively complex quantitative models. The results reveal that both time-varying and group-level characteristics play critical roles, challenging key assumptions from prior research, and that appeal outcomes are driven not only by clinical merit but also significantly by procedural factors. These findings suggest that the appeals process may inadvertently reinforce existing inequities, offering important insights into the barriers consumers face and highlighting opportunities for policy reform to promote more equitable access to care.