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Claims Denials

Analysis Reveals More About Claims Denials Tied to ACA Marketplace Plans

By Jonathan Springston, Editor, Relias Media

More than a decade after the Affordable Care Act paved the way for an online insurance marketplace, plenty of consumers appear to be battling to receive full coverage through the plans they purchased, according to an analysis of recently updated federal data.

The Kaiser Family Foundation (KFF) analyzed CMS data about non-group qualified health plans offered on HealthCare.gov. The available data applied to 2020 (made available in 2021 and updated again in 2022). On average, investigators found these providers denied more than 18% of in-network claims, with such denials reaching 80% in extreme examples.

KFF found 16% were denied for an excluded service, 10% for lack of preauthorization, and about 2% for medical necessity (one in five of these were for behavioral health services). Seventy-two percent of denials were labeled “all other reasons,” with no other specifics listed. Only one-tenth of 1% of patients appealed denials; 63% of denials were upheld.

The report authors noted other problems, including the fact these transparency data lag and are not even complete. Of 213 insurers on HealthCare.gov that reported for 2020, only 144 show complete data on in-network claims received and denied. Additionally, other studies of commercial insurance and Medicare Advantage plans indicate average denial rates are lower.

“Marketplace consumers can only see certain plan features today — premiums, deductibles, copays, and lists of covered services. They can’t see other features that may matter to them and that appear to vary dramatically, including how reliably plans pay claims,” the report authors concluded. “More robust transparency data reporting, while potentially more burdensome to insurers, could provide data useful to both regulators and consumers.”

The KFF analysis was released ahead of a different report by the American Cancer Society that shows just how important access to comprehensive insurance coverage can be. Investigators found patients without insurance were much more likely to be diagnosed with late-stage cancer and die sooner or more often.

“Our findings extend earlier research showing that lack of health insurance coverage is associated with later stage at diagnosis and worse short-term survival among individuals newly diagnosed with cancer, with more recent data and more information on long-term survival,” Jingxuan Zhao, senior associate scientist at the American Cancer Society and lead author of the study, said in a statement. “Improving access to comprehensive health insurance coverage is critical for ensuring access to care throughout the cancer care continuum, including receipt of recommended cancer screening, timely diagnosis, and quality treatment.”