Denials of Health Insurance Claims are Rising—and Getting Weirder

Fierce Healthcare | By Elisabeth Rosenthal
 
Millions of Americans in the past few years have run into this experience: filing a health care insurance claim that once might have been paid immediately but instead is just as quickly denied. If the experience and the insurer’s explanation often seem arbitrary and absurd, that might be because companies appear increasingly likely to employ computer algorithms or people with little relevant experience to issue rapid-fire denials of claims—sometimes bundles at a time—without reviewing the patient’s medical chart. A job title at one company was “denial nurse.”
 
It’s a handy way for insurers to keep revenue high—and just the sort of thing that provisions of the Affordable Care Act (ACA) were meant to prevent. Because the law prohibited insurers from deploying previously profit-protecting measures such as refusing to cover patients with preexisting conditions, the authors worried that insurers would compensate by increasing the number of denials.
 
And so, the law tasked the Department of Health and Human Services (HHS) with monitoring denials (PDF) both by health plans on the Obamacare marketplace and those offered through employers and insurers. It hasn’t fulfilled that assignment. Thus, denials have become another predictable, miserable part of the patient experience, with countless Americans unjustly being forced to pay out-of-pocket or, faced with that prospect, forgoing needed medical help.
 
A recent KFF study of ACA plans found that even when patients received care from in-network physicians—doctors and hospitals approved by these same insurers—the companies in 2021 nonetheless denied, on average, 17% of claims. One insurer denied 49% of claims in 2021; another’s turndowns hit an astonishing 80% in 2020. Despite the potentially dire impact that denials have on patients’ health or finances, data show that people appeal only once in every 500 cases.
 
Sometimes, the insurers’ denials defy not just medical standards of care but also plain old human logic. 

Read Full Article