Consumer Survey Highlights Problems with Denied Health Insurance Claims


A KFF survey of adults with health insurance discovered that more or less 6 in 10 insured adults revel in issues once they use their insurance coverage. Issues studied come with denied claims, community adequacy problems, preauthorization delays and denials, and others. The survey additionally explored how frequently shoppers can effectively get to the bottom of medical health insurance issues once they arrive and the effects of insurance coverage issues. This Knowledge Be aware takes a more in-depth take a look at insured adults who stated that previously 12 months, insurance coverage didn’t pay for care that they gained and idea used to be coated, which we will be able to confer with as “denied declare.”

Folks with non-public insurance coverage are much more likely to have denied claims than other people with public protection

The KFF Survey of Shopper Reviews with Well being Insurance coverage discovered that 18% of insured adults say they skilled denied claims previously 12 months. This downside used to be fairly extra not unusual amongst other people with employer-sponsored insurance coverage (21%) and market insurance coverage (20%), much less so amongst other people with Medicare (10%) or Medicaid (12%).

Individuals who use extra well being services and products also are much more likely to revel in denied claims. Amongst prime utilizers – sufferers who had greater than 10 supplier visits previously 12 months – 27% skilled a denied declare, whilst equivalent stocks of reasonable utilizers – who had 3-10 visits in a 12 months – skilled a denied declare (21%).  Against this, smaller stocks of sufferers who had fewer than 3 supplier visits in a 12 months skilled a denied declare (14%).

About one in 5 insured adults who used emergency room services and products (22%) or psychological well being services and products (22%) say that they had a denied declare, regardless that there’s no approach to inform from the survey if the denials had been for claims similar to those particular services and products. In the end, individuals who establish as LGBT are just about two times as prone to revel in denied claims in comparison to different shoppers (30% vs. 17%).

Folks with denied claims record extra problem figuring out protection

Issue figuring out sides in their well being protection used to be reported extra frequently amongst shoppers who skilled denied claims in comparison to others. A majority of customers who skilled denied claims record problem figuring out what their medical health insurance covers (65%), what they’ll owe out of pocket (57%), and their EOBs (52%). It isn’t transparent whether or not those demanding situations figuring out protection give a contribution to claims being denied, or whether or not denied claims compound the confusion shoppers differently revel in figuring out their protection.

Shoppers with denied claims had been much more likely to revel in different sorts of insurance coverage issues

Shoppers who skilled denied claims had been a lot more prone to have additionally encountered different issues the usage of their protection previously 12 months. On reasonable, insured adults with denied claims skilled about 4 several types of insurance coverage downside in a 12 months. In comparison to insured adults who didn’t revel in denied claims, those that did had been a minimum of two times as prone to have skilled different insurance coverage issues requested about within the survey (corresponding to attaining the restrict on coated services and products, no longer with the ability to in finding or get right of entry to an in-network supplier together with a psychological well being supplier, and prior authorization issues).

Shoppers frequently can’t get to the bottom of issues satisfactorily

Amongst insured adults who record insurance coverage issues previously 12 months, part (50%) say the most important downside that they had with their insurance coverage used to be solved to their pride. The survey didn’t ask shoppers to specify which in their insurance coverage issues used to be the “largest.” On the other hand, shoppers whose issues incorporated a denied declare had been part as prone to say their largest downside used to be resolved satisfactorily in comparison to the ones whose issues didn’t come with a denied declare (29% vs 59%), suggesting that denied claims could also be particularly difficult for shoppers to unravel on their very own, regardless that it will not be for loss of attempting.

About 8 in ten (84%) shoppers with denied claims took some motion to check out to get to the bottom of the most important downside that they had with their insurance coverage – corresponding to calling the insurance coverage corporate or asking their physician or a pal or circle of relatives member for lend a hand – and 15% filed a proper enchantment.

Even so, like insured shoppers general, maximum of those that skilled denied claims have no idea whether or not they have got enchantment rights (69%) or what govt company to name for lend a hand (86%).

The Reasonably priced Care Act established Consumer Assistance Programs (CAPs) whose tasks come with serving to shoppers resolution insurance coverage questions, get to the bottom of insurance coverage issues, and record appeals.  By means of legislation, non-public insurance coverage plan denial statements should come with a realize with touch knowledge for the CAP (if one is to be had) and indicating this program can lend a hand shoppers record an enchantment. Most effective 3% of adults who skilled insurance coverage issues stated they contacted a CAP for lend a hand, regardless that 79% of all insured adults stated they might be a minimum of fairly prone to search lend a hand from a CAP for lend a hand with insurance coverage issues.   

Severe well being and monetary penalties may end up from insurance coverage issues, together with denied claims

The survey requested insured adults in regards to the penalties in their insurance coverage issues – whether or not wanted care used to be behind schedule or no longer gained, well being standing declined, and/or out-of-pocket prices larger. As a result of some other people with denied claims additionally skilled a couple of different sorts of insurance coverage issues in the similar 12 months, there’s no approach to hyperlink penalties to a unmarried form of downside. On the other hand, evaluating penalties for adults whose issues did or didn’t come with denied claims, the ones with denied claims had been about two times as prone to have issues previously 12 months getting access to care or to have well being standing decline, and greater than thrice as prone to have hastily upper out-of-pocket prices.


Just about 1 in 5 insured adults (18%) stated they skilled a denied declare previously 12 months.  Amongst individuals who use essentially the most well being care, 27% skilled a denied declare. Claims denials seem to be attached to the complexity of insurance coverage for shoppers; whilst part of all insured adults in finding some facet of insurance coverage obscure, amongst those that revel in claims denials it’s just about 8 in 10. As well as, shoppers whose issues come with a denied declare are a long way much less prone to have resolved their largest insurance coverage downside satisfactorily in comparison to the ones whose issues don’t come with denied claims.  Severe well being and monetary penalties stand up as an immediate results of insurance coverage issues, and shoppers whose issues come with denied claims are a long way much more likely to have wanted care behind schedule or denied, to revel in a decline in well being standing, and to stand upper out-of-pocket prices.

Maximum shoppers with denied claims (69%) have no idea that they have got enchantment rights, and the overwhelming majority (85%) don’t record formal appeals. Appeal rights range relying on the kind of protection as do regulations or submitting appeals and the method can also be complicated. Methods to simplify the appeals procedure and make client notices about find out how to enchantment extra distinguished and simple to know would possibly lend a hand. Even so, as a result of individuals who want to enchantment medical health insurance choices will maximum frequently be those that use numerous well being services and products – and who could also be too ill to suggest successfully for themselves – help navigating the insurance coverage claims and appeals procedure may be vital.

Congress licensed established order of Consumer Assistance Programs (CAPs) to lend a hand other people get to the bottom of their insurance coverage issues and record appeals, regardless that shoppers with denied claims infrequently name on CAPs for lend a hand.  Connecticut not too long ago applied a demand on well being insurers to position a distinguished, plain-language realize about CAP help at the entrance web page of all medical health insurance denials, which has resulted in an increase in case referrals to that place of job. About 8 in ten insured adults (79%) say they might most probably name on any such program for lend a hand with insurance coverage issues. CAPs don’t exist in all states, then again, and Congress has no longer appropriated price range for CAPs since 2010.

The KFF survey can’t inform how frequently claims denials are fallacious, or the level to which client difficulties figuring out the complexity of well being protection would possibly give a contribution to denials. Greater oversight may lend a hand provide this data.  A federal legislation requiring non-public plans to divulge knowledge on denied claims stays largely unimplemented. Such knowledge might be a very powerful instrument to observe developments and variations in denial charges, and to carry insurers responsible to satisfy felony requirements, corresponding to necessities to offer psychological well being parity and protection for marvel scientific expenses.

This paintings used to be supported partially via a grant from the Robert Wooden Johnson Basis. The perspectives and research contained right here don’t essentially mirror the perspectives of the Basis. KFF maintains complete editorial keep an eye on over all of its coverage research, polling, and journalism actions.

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