In 2020, amid a global pandemic, health insurers on the Affordable Care Act marketplaces denied close to one-fifth of all in-network claims, according to a Healthcare Dive article citing Kaiser Family Foundation (KFF).
In North Carolina alone, Blue Cross Blue Shield (BCBSNC) denied just shy of 15%, or 2,901,677, of claims in 2020. That’s a pretty hefty piece of denial pie.
Nationwide, 42 million claims were denied for reasons including “lacking prior authorization, excluded services and medical necessity,” according to the article.
Sometimes all this jargon — claims, prior authorizations, et cetera — can obscure the reality of what’s happening. To put it simply, almost 3 million patients in North Carolina — with health insurance — went to in-network healthcare facilities but were denied coverage.
Yet by citing the excuses of “prior authorizations” and “medical necessity,” insurers are ironically admitting the underlying issue with our nation’s healthcare system: themselves.
Insurers, not doctors, get to decide what kind of healthcare services you actually need.
I’m sure we all feel better and healthier already.
To make matters worse, in a country with mental illness and addiction on the rise, “one in five medical necessity [claim] denials were for behavioral health services,” according to the article.
So, what should you do if you’re one of those ‘chosen few’ (err, millions) of denials? You could try to appeal, but insurers are banking that you won’t. For one, consumers rarely do appeal their denied claims. It’s estimated that consumers appealed their “denied claims at a rate of about one-tenth of 1%.” And second, when they do appeal, it’s often ineffective — insurers upheld 63% of appealed denials.
If these numbers don’t illustrate just how much insurers are the biggest roadblock to care, we don’t know what will.