ProPublica: No one knows how often payers deny claims

No single source of information exists where consumers can view how often a specific health plan denies coverage for in-network and out-of-network claims, but state and federal agencies have the ability to change that, according to a June 28 ProPublica report.

While the ACA provided federal regulators with more authority to collect denial rates data from payers, most of the information available today is "essentially meaningless," according to the report.

CMS collects denial rates only for in-network providers, though it is working to expand out-of-network reporting requirements for marketplace plans. Two states collect denial rates, but the data covers only a small percentage of their populations. The National Association of Insurance Commissioners collects the most comprehensive information, including data on out-of-network and pharmacy denials and prior authorization, though none of the information is released publicly. 

From the limited claims data that is available publicly, it is estimated that payers deny between 10 percent and 20 percent of all claims. It is not possible to estimate denial rates for specific plans or services.

Insurance trade groups told ProPublica that most claims are approved and issues on the provider side can lead to denials.

"Denial rates are not directly comparable from one health plan to another and could lead consumers to make inaccurate conclusions on the robustness of the health plan," a Blue Cross Blue Shield Association spokesperson told the publication.

"More abstract data about percentages of claims that are approved or denied have no context and are not a reliable indicator of quality — it doesn't address why a claim was or was not approved, what happened after the claim was not approved the first time, or how a patient or their doctor can help ensure a claim will be approved," an AHIP spokesperson told ProPublica. "Americans deserve information and data that has relevance to their own personal health and circumstances."

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