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
Hospitals Worry About Medicaid Cuts
Hospitals are worried about the major Medicaid cuts that could occur under a budget reconciliation bill passed by the GOP Congress in 2025. Hospitals are readying by reducing costs, looking at other revenue streams, and lobbying Congress about the fallout. Hospitals say uncompensated care costs could surge and recovering margins decline.
(Article may require a subscription.)
#hospitals #medicaid #congress
FL Blue Lays Off 3% of Workforce
Citing regulatory challenges and rising healthcare costs, GuideWell, the parent company of health insurer Florida Blue, is laying off about 3% of its total workforce. The move is part of efforts to streamline operations.
Other companies like Blue Shield of California and Blue Cross and Blue Shield of Michigan have announced layoffs and cutbacks as well due to financial pressures.
(Article may require a subscription.)
#flblue #healthplans #margins #layoffs
https://www.modernhealthcare.com/labor/guidewell-layoffs-florida-blue
Wall Street Journal Opposes RFK, Jr.
The Wall Street Journal’s editorial board came out against Robert F. Kennedy Jr., President Donald Trump’s nominee for Health and Human Services secretary, in a blistering editorial Sunday. The Journal cites his anti-vaccine advocacy and money he received for referring clients to law firms that have sued vaccine makers. Kennedy will appear before two Senate committees this week for a confirmation hearing.
Still, thus far GOP senators have largely kept their power dry on Kennedy. Advocates are readying for the likelihood that they will need to work with Kennedy.
Additional articles: https://insidehealthpolicy.com/daily-news/wsj-rfk-s-history-misinformation-should-disqualify-him-lead-hhs and https://apnews.com/article/rfk-senate-confirmation-vaccines-trump-health-f000bbb5c5f2c800299a7ff8e64fee0b
(Some articles may require a subscription.)
#rfkjr #hhs #healthcare #trump #congress
https://thehill.com/homenews/media/5108598-wall-street-journal-rfk-jr-hhs-trump-anti-vax
Wakely Issues Analysis Of Advance Notice
Wakely issued its normal robust analysis of the Advance Notice and dives deep into all the rates and policies impacting Medicare Advantage (MA) and Part D. Given Wakely’s granular analysis, it finds that the risk adjusted benchmark will increase by about 1.86%. This is slightly lower than the 2.23% that was in the Centers for Medicare and Medicaid Services’ (CMS) press release. Risk score trends are not included.
#medicareadvantage #rates #cms
https://www.wakely.com/blog/summary-impacts-of-2026-medicare-advantage-advance-notice/
— Marc S. Ryan
