17% of in-network claims denied by ACA plans

On average, 17.4 percent of in-network claims were denied by payers that offered ACA plans in 2019, according to a new Kaiser Family Foundation report

For the study, researchers analyzed CMS data from 2018 and 2019 on individual health plans on the ACA marketplace and off the exchange. The researchers were looking to identify the rates of claim denials and appeals to determine if transparency initiatives were effective. Of the 181 insurers offering plans, 122 had complete data on in-network claims. Together there were 232.8 million in-network claims analyzed by researchers. 

Researchers found that the average rate of in-network denials was 17.4 percent, or 40.4 million in-network claims in 2019. This compares to 14 percent of claims being denied in 2018.

However, denial rates by each payer varied significantly. Some insurers denied just 1 percent of claims, while others denied 57 percent of claims. In 2019, 34 payers had a denial rate for in-network claims of less than 10 percent, 45 payers denied 10 percent to 20 percent, 32 payers denied 20 percent to 30 percent and 11 payers denied more than 30 percent. 

Some of the insurers with the highest denial rates were, Blue Cross Blue Shield of Tennessee, which denied 57 percent, Anthem BCBS of Georgia, which denied 40.5 percent, and Anthem BCBS of Maine, which denied 40.4 percent.

In 2019, 18 percent of payers reported denying a claim because the service was not covered, and 9 percent said they denied claims due to a prior authorization or referral issue.

However, most of the claims, 72 percent, were denied for "other reasons."

"Nearly three-quarters of in-network claims were denied for 'some other' reason indicates there is more to learn about why plans deny in-network claims," the researchers wrote. 


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