Millions of Americans in the past few years have run into this experience: filing a health-care insurance claim that once might have been paid immediately but instead is just as quickly denied.
If the experience and the insurer’s explanation often seem arbitrary and absurd, that might be because companies appear increasingly likely to employ computer algorithms or people with little relevant experience to issue rapid-fire denials of claims — sometimes bundles at a time — without even reviewing the patient’s medical chart; a job title at one company was “denial nurse.”
It’s a handy way for insurers to keep revenue high — and just the sort of thing that provisions of the Affordable Care Act were meant to prevent.
Because the law prohibited insurers from deploying a number of previously profit-protecting measures such as refusing to cover patients with preexisting conditions, the authors worried that insurers would compensate by increasing the number of denials.
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A recent study by the Kaiser Family Foundation (KFF) of plans on the Affordable Care Act marketplace found that even when patients received care from in-network physicians — doctors and hospitals approved by these same insurers — the companies in 2021 nonetheless denied, on average, 17 percent of claims.
One insurer denied 49 percent of claims in 2021; another’s turndowns hit an astonishing 80 percent in 2020.
Despite the potentially dire impact that denials have on patients’ health or finances, data shows that people appeal only once in every 500 cases.
