For the analysis, researchers examined ACA transparency data from CMS to look at nearly 230 million claims submitted to 130 insurers offering individual market coverage through healthcare.gov in 2017.
The analysis found that among the 130 insurers in healthcare.gov states with complete data, 42.9 million of 229.8 million in-network claims received were denied in 2017.
The analysis also found that enrollees don’t often appeal claims denials. Information from insurers with data on submitted, denied and appealed in-network claims showed that in 2017, enrollees appealed fewer than 200,000 of more than 42 million denied claims. That’s an appeal rate of 0.5 percent.
The Kaiser Family Foundation said data from CMS does not indicate the reasoning for claims denials. It speculated that reasons could include improperly submitted or duplicative claims or denials for services that the insurer determined weren’t medically necessary.
Researchers said they found that during the appeal process insurers typically uphold their original decision. In 2017, insurers only overturned 14 percent of appealed denials.
Access the full analysis here.
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