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State’s ACA marketplace issuers deny 13% of claims on average
Report: Florida ACA Marketplace Issuers Deny 13% of Claims on Average
By Jarrod Fowler, MHA, FMA Director of Healthcare Policy and Innovation | June 1, 2023
According to data
by the Kaiser Family Foundation, HealthCare.gov issuers in Florida denied an average of 13.1% of in-network claims in 2021 — below the national average of 17%, but still substantial. Before delving into the details, however, it is worth noting that the data provided below may be imperfect. This is, according to KFF, because the “data that are collected are not audited, for example, to ensure issuers report data consistently.”
Denial rates vary substantially by issuer
The in-network denial rate detailed in the report varied substantially by issuer. For instance, Health Options, Inc. had a denial rate of 13.3% in 2021 while BCBS of Florida had a denial rate of 10%. Bright Health Insurance Company of Florida had a denial rate of 5.7% and Celtic Insurance Company had a denial rate of 41.9%, according to the report. Other Florida issuers had in-network denial rates ranging from 6.6% to 26.9%.
The reason for these denials also varied substantially by issuer and plan. For instance, 24% of Cigna’s Florida Silver EPO marketplace plan claim denials were due to medical necessity. Comparatively, 18% of Molina’s Bronze Expanded HMO claim denials were related to prior authorization. The report also found that consumers rarely filed either internal appeals or external appeals challenging claim denials.
The report concludes by stating, “The federal government has not expanded or revised transparency data reporting requirements in years and does not appear to conduct any oversight using data that are reported by marketplace plans. As a result, consumers are not provided any information about how reliably marketplace plan options pay claims and plans reporting high claims denial rates do not appear to face any consequences.”
Findings indicate need for greater oversight
Claim denials are hugely problematic in medical practice. When claims are denied for erroneous or inappropriate reasons, this threatens the economic viability of medical practice and can erode patients’ access to care. In addition, appealing claim denials can consume considerable time and resources. The findings of this report appear to indicate that greater oversight of claim denials is warranted.
As the report notes, “… in Florida, where the average denial rate was 13% in 2021, the five issuers with largest market shares reported denial rates for in-network claims ranging from 15% to 42%.” Such tremendous variation warrants a detailed explanation that the public can readily access and easily understand, as patients ultimately will suffer if they receive denials for treatments that should have been approved.