ACA insurers deny 20% of claims: report
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Affordable Care Act marketplace insurance plans denied an average of 1 in 5 claims in 2023, with two carriers denying as many as 1 in 3, according to a KFF analysis.
Why it matters: Claim denials are one of consumers' chief complaints with their health insurance and can make it harder for people to pay their medical bills.
By the numbers: Federal marketplace insurance plans reported receiving 425 million claims in 2023, according to KFF's analysis of federal data.
- 92% were for in-network services, and insurers denied an average of 19% of those.
- Plans denied 37% of the remaining claims that were out of network, for an overall average of 20% of claims denied.
- Those rates don't include claims that plans initially denied but ultimately paid after they were resubmitted, KFF said. Marketplace consumers appealed less than 1% of denied claims in 2023.
Nine health insurance parent companies that received more than 5 million claims denied in-network claims at a rate of more than 20%, according to KFF's analysis. Blue Cross Blue Shield of Alabama had the highest rate of denials at 35%.
The other side: Health plans approve the majority of claims submitted, noted Chris Bond, spokesperson for insurance trade organization AHIP.
- "There are valid reasons for the small percentage of claims subject to further review and we recognize this can be frustrating. ... An appeal is always available for patients and providers with internal and external review processes in place and communicated to health plan members," Bond said in a statement.
- There are also situations where a claim may be recorded as denied without causing harm to patients, like when claims list items that don't require payment, a UnitedHealth Group spokesperson told Axios.
- UnitedHealthcare added that the company believes it's misleading to say it denies 32% of claims because it's based on a 2% sample of the company's total claims volume.
About 12 million people selected plans on HealthCare.gov for coverage in 2023.
