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The data keeps rolling in — claim denials continue to impact patient care

Nearly 1 in 5 insured Americans experience claim denials

Health insurance companies continue to cook up creative strategies to shortchange health systems through underpayments, non-payments, and — it’s the big one! — claim denials. These strategies reduce what gets reimbursed to healthcare providers, which, in turn, impacts patient care — the care that patients specifically pay for insurance to cover.

But don’t take our word for it. Time and again, we get evidence of these insurer tactics through quantitative data. For instance, a recent Kaiser Family Foundation (KFF) survey of adults with health insurance found that roughly 6 in 10 insured adults experience problems when they use their insurance. Some of the problems that individuals surveyed experience include network adequacy issues, preauthorization delays, and denied claims.

What’s particularly damning is that approximately 18 percent of insured adults say they experienced denied claims in the past year. That means that for nearly 1 in 5 individuals with insurance, their insurance company refused to pay for their healthcare services.

And the more you need healthcare services, the more likely you are to experience claim denials, according to report findings. For instance, for patients who had more than 10 provider visits in the past year, 27 percent of those individuals experienced a denied claim. Meanwhile, patients with fewer than three provider visits in a year experienced a denied claim 14 percent of the time.

So, let’s get this straight — the more health challenges you experience, the more likely it is that you’ll face denials and administrative headaches, which hinder your attempts to find the right course of treatment and arguably make your health worse. And so, the cycle continues.

To measure the consequences of their insurance problems, the survey found that those with denied claims were about twice as likely to have problems in the past year accessing care or to have health status decline — and more than three times as likely to have unexpectedly higher out-of-pocket costs.

And unfortunately, many people don’t know how to speak up. Sixty-nine percent of consumers with denied claims do not know they can appeal the claim, while 85 percent of consumers do not file formal appeals, according to KFF.

There are some, though, who do speak out against these payor practices. Last month, a group of protestors in Portland, Maine, gathered outside the office of Aetna Health Insurance with signs and shared personal experiences about unfairly denied claims. The Maine People’s Alliance said companies like Aetna routinely deny claims as part of the business model, even as they make large profits. The rally was just 1 of 15 events happening around the country as part of a national campaign to demand reform of large private insurers.

The group of protestors also delivered a letter with demands, two of which included coverage for all treatment recommended by medical professionals and more transparency around claim denials.

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