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KFF Finds Major Claims Denials In Exchanges

The Kaiser Family Foundation (KFF) finds in a new study that health insurers selling Marketplace plans in states that use the federal Exchange rejected 19% of in-network claims on average in 2023. That is up from 16% in 2022. The rate has been steady over time, ranging from a 14% low in 2018 to a 19% high in 2015 and 2023. Insurers denied 37% of out-of-network claims in 2023.

There is a huge range in denial rates among plans, from 1% to 54%. For high volume insurers, the range was 13% to 35%.

“Other reasons” represented the largest category of denials (34%), with 16% tagged as excluded services, 9% as lack of prior authorization or referral, and 6% as lack of medical necessity. Other common reasons for denials included administrative issues (18%) and exceeding benefit limits (12%).

While I think health plans do need to reform some aspects of claims scrutiny, the reality is that health plans have a duty to review claims and that in many cases denials are the fault of providers for not obtaining necessary approvals or submitting required documentation. KFF’s study does not cover the health plan side of things very well.

KFF press release and analysis: https://www.kff.org/affordable-care-act/press-release/healthcare-gov-insurers-denied-nearly-1-in-5-in-network-claims-in-2023-but-information-about-reasons-is-limited-in-public-data/ and https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans-in-2023/

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#claimsdenials #healthplans #providers #exchanges #aca #obamacare

https://www.modernhealthcare.com/insurance/unitedhealth-hcsc-exchange-claims-denials-kff

Change Healthcare Updates Number Of Those Impacted By Cyberattack

The Change Healthcare cyberattack brought much of healthcare to a halt in 2024 for many months. UnitedHealth Group, Change’s parent, earlier said that 100 million people were impacted. It now has updated that number to 190 million or about 57% of the nation’s population.

The cyberattack posed a significant financial cost to UnitedHealth Group, with the company projecting that it would take a $2.9 billion hit. More important, it had huge costs for providers, health plans, pharmacies, and other healthcare entities. All of these entities relied on Change’s vast service and processing systems.

The attackers used stolen credentials and breached a server that did not have two-factor authentication – a rookie mistake in security. The attackers were paid a ransom yet still took information from the servers.

United says it is not aware of a misuse of data, but that is little solace or relief for those impacted. How can you trust the healthcare monolith after it lied and failed to inform throughout the crisis. United was clearly negligent when it came to security, its lack of preparedness for such an event, and its failure to modernize infrastructure and technology. It will see far greater costs than it anticipates. Providers, health plans, and pharmacies should sue for the billions in costs due to the event.

In many ways, this is a lesson in the arrogance of big health plans and why vertical integration has gone too far. Profit and margins were more important than good governance of healthcare data.

#changehealthcare #unitedhealthcare #cyberattacks

https://www.fiercehealthcare.com/payers/unitedhealth-estimates-190m-people-impacted-change-healthcare-cyberattack

Elevance Health Reports Q4 and 2024 Financial News

After some rocky news from UnitedHealth Group earlier, Elevance Health reported some mixed financial news as well. Elevance said it would grow 7% to 9% in Medicare Advantage (MA). The company did say it is attacking growth prudently given rate concerns and utilization trends. Elevance also says that while MA rates are moving in the right direction, rates for 2026 will be inadequate based on the Advance Notice recently released.

But like United, year-over-year margins decreased even though Elevance beat Wall Street. Its services unit, Carelon, showed robust revenue growth.

On Medicaid, Elevance said Medicaid rate pressures could ease in 2H 2025 and that it is encouraged by some rate hikes it is seeing from states.

As has been seen with other insurers, Elevance’s all lines of business medical loss ratio (MLR) rose considerably to 92.4% in the fourth quarter, up from 89.5% in the third quarter and from 89.2% in the fourth quarter of 2023.

Additional articles: https://www.modernhealthcare.com/insurance/elevance-health-medicaid-costs-2025 and https://www.healthcaredive.com/news/elevance-2024-results-medicaid-medicare-advantage/738024/ and https://www.beckerspayer.com/payer/2026-medicare-advantage-rates-inadequate-elevance-execs-say.html and https://www.healthcarefinancenews.com/news/elevance-pulls-418-million-q4-profit

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#elevancehealth #healthplans #mlrs #margins #medicareadvantage #medicaid #managedcare

https://www.fiercehealthcare.com/payers/elevance-health-reports-418m-profit-q4

CMS Appealing UnitedHealthcare’s 2025 Stars Win

In very odd timing, the Centers for Medicare and Medicaid Services (CMS) has said it will appeal a federal judge’s order to recalculate UnitedHealthcare’s Medicare Advantage (MA) Star ratings. CMS did not state the grounds for its appeal. 

Coming out of a federal judge’s decision siding with United in its suit, CMS did revise UnitedHealthcare’s and Centene’s star rating scores for 2025. UnitedHealthcare received higher ratings in 12 contracts and Centene in seven contracts. Centene’s suit closely mirrored United’s.

Additional article: https://www.modernhealthcare.com/legal/cms-unitedhealth-medicare-advantage-star-ratings-appeal

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#cms #stars #medicareadvantage

https://www.fiercehealthcare.com/payers/cms-will-appeal-unitedhealthcares-ma-star-ratings-court-win