Health insurers and health plan administrators say the claim review process helps hold coverage costs down, by making sure that patients are getting appropriate, covered care at the right time from the right kinds of providers.
Providers and patients hate denials. They see denials as an insult and, possibly, even a violation of human rights. They may be quick to call HR, benefits managers, members of Congress and the local TV station about problems with getting a big medical bill paid.
KFF crunched data from HealthCare.gov to come up with a partial answer to a frequently asked employer question: Which health insurers and managed care companies are the most likely to deny claims?
Recommended For You
Related: Investors ask UnitedHealthcare to account for claims denial practices
For a look at the carriers with more than 10 million in-network claims received by HealthCare.gov plans in 2023, ranked in terms of in-network denial rates, see the gallery accompanying this article.
Three of the carriers are nonprofit organizations or are member-owned, and four are for-profit health insurance giants.
Note that the figures are denial rates for individual coverage claims, not for group health coverage claims, and that the bare denial rates do not provide any context.
The ideal denial rate data would come with claim review statistics from claim auditors, to show whether some carriers' providers send in a higher percentage of questionable claims or some carriers are better than average at detecting what the auditors agree are questionable claims.
The bare denial rates may also fail to distinguish between carriers operating in a normal environment and carriers facing major disruptions, such as big provider network shifts that suddenly turn in-network providers into out-of-network providers and leave patients, providers and the carriers themselves struggling to keep up.
© Touchpoint Markets, All Rights Reserved. Request academic re-use from www.copyright.com. All other uses, submit a request to [email protected]. For more inforrmation visit Asset & Logo Licensing.
Allison Bell
Allison Bell, a senior reporter at ThinkAdvisor and BenefitsPRO, previously was an associate editor at National Underwriter Life & Health. She has a bachelor's degree in economics from Washington University in St. Louis and a master's degree in journalism from the Medill School of Journalism at Northwestern University. She can be reached through X at @Think_Allison.
