18% of healthcare.gov claims are denied, Kaiser Family Foundation finds

Healthcare.gov insurers denied about 18 percent of in-network claims in 2020, according to a July 5 Kaiser Family Foundation report.

Out of the 213 major medical issuers in healthcare.gov states that reported for the 2020 plan year, 144 of those show complete data on in-network claims received and denied. Together. these issuers reported 230.9 million in-network claims received, and 42.3 million were denied, resulting in an average in-network claims denial rate of 18.3 percent. 

Of denials with a reason other than being out of network, 16 percent were denied because the claim was for an excluded service, 10 percent were denied because there was no preauthorization or referral, and about 2 percent were deemed not medically necessary. Among the claims identified as medical necessity denials, 1 in 5 were for behavioral health services. Most plan-reported denials (72 percent) were classified as "all other reasons," without a specific reason.

The data was released by CMS on claims denials and appeals for non-group qualified health plans offered on healthcare.gov for the 2020 plan year.

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