Insurers of certified well being plans on HealthCare.gov denied about one in 5 in-network claims and 37% of out-of-network claims in 2023, in response to a brand new evaluation from KFF.

KFF is a nonprofit well being coverage analysis, polling and information group. The evaluation checked out information from the Facilities for Medicare and Medicaid providers, together with 425 million claims submitted to 175 insurers promoting market protection in 2023.

The researchers discovered that the in-network denial price ranged from 1% to 54% amongst HealthCare.gov issuers. There was additionally broad variation by state. Alabama had the very best in-network denial price for HealthCare.gov at 34%, whereas South Dakota had the bottom at 6%. 

Amongst HealthCare.gov father or mother corporations that acquired greater than 5 million claims in 2023, those with the very best in-network declare denial charges have been Blue Cross Blue Defend of Alabama at 35%, UnitedHealth Group at 33% and Well being Care Service Company at 29%. GuideWell Mutual Holding had the bottom at 13%.

There was restricted information on the explanation in-network claims have been denied. Nonetheless, in response to the obtainable information, the most typical motive for a denial was a basic “different” motive at 34%, adopted by an administrative motive (18%) and the service being excluded (16%), in response to KFF.

KFF additionally discovered that customers don’t enchantment denied claims usually, with fewer than 1% of denials appealed. After they did enchantment, insurers upheld 56% of their authentic choices. It’s price noting, nevertheless, that many shoppers don’t know that they will enchantment claims. Solely 40% of shoppers assume they’ve a authorized proper to enchantment to a authorities company or unbiased medical knowledgeable, KFF stated.

The report comes amid rising public outrage over insurer practices.

“Though analysis and investigations into well being insurer practices have garnered consideration from lawmakers and affected person advocates over the previous a number of years, the December 2024 killing of UnitedHealthcare’s CEO ignited broad public outrage over insurer claims denials,” the researchers stated.

“Whereas prospects for important modifications in response to the general public outrage could also be restricted, curiosity in offering the general public with extra transparency about how insurer claims assessment and appeals function might, in the identical method as offering extra correct value transparency data, higher allow shoppers and employers to make extra knowledgeable selections when buying non-public protection,” KFF continued.

The group gave a number of suggestions for the way transparency could be improved, together with offering extra particular data in present datasets, providing claims denial data on employer protection and launching state-level initiatives.

Photograph: Mironov Konstantin, Getty Pictures