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About: De facto denial     Goto   Sponge   NotDistinct   Permalink

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De facto denial or functional denial is a situation that can occur in health insurance and workers' compensation insurance when a claim is not denied outright, but in practical terms it is not covered. If cost reduction by an insurer is the reason for de facto denials as part of utilization management, it can lead to healthcare rationing through denials of care or coverage, delays in care, and unexpected financial risks to patients.