About 1 in 5 claims sent to fully insured commercial health insurers in Massachusetts were denied in 2024, according to February findings from the Massachusetts Health Policy Commission.
These insurers submit claim denial data to the commission’s Office of Patient Protection and the Massachusetts Division of Insurance each year. The health insurers reported 45.9 million claims overall in 2024.
Here are five notes from the report:
1. The carriers with the steepest denial rates included UnitedHealthcare at 28%, Harvard Pilgrim Health Plan and HPHC Insurance Co. at 27% and Aetna at 25%.
2. The most common cause for a denial was administrative issues. Strictly clinical rationales made up, at most, 1% of denials for any insurer. Clinical reasons included medical necessity and experimental/investigational denials.
3. Despite a slight increase in the share of claim denials between 2022 and 2024, the percentage of administrative denials held steady.
4. Institutional outpatient claims — such as outpatient same-day surgeries, radiology in hospital outpatient departments and emergency department care — had the highest denial rate at 23%, whereas professional mental health claims had a 10% rate.
5. There was also a disparity in the reasoning for claim denials: 80% of denied professional medical/surgical claims were due to administrative issues, such as an incomplete claim, coding error, duplicate claim or coverage, or another administrative problem. However, 67% of denied professional mental health claims were rooted in administrative concerns.
