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/
(Some articles may require a subscription.)
#claimsdenials #healthplans #providers #exchanges #aca #obamacare
https://www.modernhealthcare.com/insurance/unitedhealth-hcsc-exchange-claims-denials-kff
