Marketplace Insurers
Denied Nearly 1 in 5 In-Network Claims in 2020, though It’s Often Not
Clear Why
Denial Rates Vary
Widely Across Insurers from a Low of 1% to a High of 80%
Healthcare.gov
marketplace insurers denied nearly one out of every five claims (18%)
submitted for in-network services in 2020, though why the denial rates
are so high and the ultimate consequences for consumers are difficult to
access from the publicly available data, a new KFF
analysis finds.
The Affordable Care Act requires insurers to report data about claims
denials and appeals to encourage transparency about how insurance
coverage works for enrollees. The analysis examines data released by the
Centers for Medicare and Medicaid Services on more than 230 million
claims submitted to 144 insurers selling marketplace coverage in 2020,
the most recent year available.
The analysis finds a huge variation across insurers, which have average
denial rates as low as 1% and as high as 80%. Denial rates also vary by
state, though insurers within the same state often show wide variations
as well. In Florida, for example, the average denial rate was 15%, but
the three insurers with the largest market share of enrollees reported
denial rates of 10.5% (Florida BCBS), 11.1% (Health Options), and 27.9%
(Celtic Insurance).
The CMS data include some information about why in-network claims are
denied, though the vast majority (72%) fall into a broad category of “all
other reasons,” likely including administrative or paperwork errors and
other issues.
Relatively few claims cite a specific reason such as lack of prior
authorization or referral (10%), an excluded service (16%) or lack of
medical necessity (2%). Among the claims denied for reasons of medical
necessity, about 1 in 5 involved behavioral health services.
Consumers appealed few of the denied in-network claims in 2020, with
fewer than 61,000 appeals in 2020, reflecting just over one-tenth of 1%
of those denials. Following those appeals, insurers usually upheld their
initial denials (63%), and consumers rarely took the next step to file an
external appeal.
The analysis, as well as data files with the insurer- and state-specific
information, is available online.
|
.png?width=1200&upscale=true&name=Just%20Released%20Header_1%20(1).png)
No comments:
Post a Comment