Insurers of certified well being plans on HealthCare.gov denied about one in 5 in-network claims and 37% of out-of-network claims in 2023, in keeping with a brand new evaluation from KFF.
KFF is a nonprofit well being coverage analysis, polling and information group. The evaluation checked out information from the Facilities for Medicare and Medicaid providers, together with 425 million claims submitted to 175 insurers promoting market protection in 2023.
The researchers discovered that the in-network denial fee ranged from 1% to 54% amongst HealthCare.gov issuers. There was additionally huge variation by state. Alabama had the best in-network denial fee for HealthCare.gov at 34%, whereas South Dakota had the bottom at 6%.
Amongst HealthCare.gov father or mother firms that obtained greater than 5 million claims in 2023, those with the best in-network declare denial charges had been Blue Cross Blue Protect of Alabama at 35%, UnitedHealth Group at 33% and Well being Care Service Company at 29%. GuideWell Mutual Holding had the bottom at 13%.
There was restricted information on the rationale in-network claims had been denied. Nevertheless, in keeping with the obtainable information, the commonest motive for a denial was a common “different” motive at 34%, adopted by an administrative motive (18%) and the service being excluded (16%), in keeping with KFF.
KFF additionally discovered that customers don’t attraction denied claims typically, with fewer than 1% of denials appealed. After they did attraction, insurers upheld 56% of their authentic selections. It’s price noting, nonetheless, that many shoppers don’t know that they will attraction claims. Solely 40% of shoppers assume they’ve a authorized proper to attraction to a authorities company or impartial medical professional, KFF mentioned.
The report comes amid rising public outrage over insurer practices.
“Though analysis and investigations into well being insurer practices have garnered consideration from lawmakers and affected person advocates over the previous a number of years, the December 2024 killing of UnitedHealthcare’s CEO ignited broad public outrage over insurer claims denials,” the researchers mentioned.
“Whereas prospects for important adjustments in response to the general public outrage could also be restricted, curiosity in offering the general public with extra transparency about how insurer claims evaluation and appeals function might, in the identical means as offering extra correct value transparency info, higher allow shoppers and employers to make extra knowledgeable selections when buying personal protection,” KFF continued.
The group gave a number of suggestions for the way transparency might be improved, together with offering extra particular info in present datasets, providing claims denial info on employer protection and launching state-level initiatives.
Photograph: Mironov Konstantin, Getty Pictures
