ACA Plans: High Claim Denial Rates

A study from the Kaiser Foundation, not to be confused with Kaiser health insurance, shows an average of 19% of initial in-network claims are denied in the individual market. Very few denials are appealed and only 14% of appeals result in a change in the claim results…


In this report, we analyze transparency data released by the Centers for Medicare and Medicaid Services (CMS) to examine claims denials and appeals among issuers offering individual market coverage on healthcare.gov from 2015-2017. We find that, across issuers with complete data, 19% of in-network claims were denied by issuers in 2017, with denial rates for specific issuers varying significantly around this average, from less than 1% to more than 40%. We also find that consumers rarely appeal claims denials to their issuers, and when they do, issuers typically uphold their original decision. Healthcare.gov consumers appealed less than one-half of one percent of denied claims, and issuers overturned 14% of appealed denials.

There are significant questions about the data and how it’s being reported (i.e. read the whole thing).

On the surface, this simply is NOT good news for such expensive insurance. I suspect there are some interesting factoids when they look under the hood.

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