From the
widely-cited article on the statistics:
- It is not an overall rate, The statistics for individual companies whose stats are called out are for marketplace plans (individual & family), not employer- or government-based, which is a small slice of the overall: "Data does not include employer plans, Medicare or Medicaid."
- Also is based on data from just 31 states, per the methodology notes.
- The methodology also states that the overall estimated rate of denials (19%) is "not an average of the companies [highlighted in the report]. The average also includes the smaller brands that are not listed in our report."
- The methodology states that that rate appears to be based on final resolution of claims. "Overall, 19% of in-network health insurance claims for marketplace plans in 2023 were denied. That doesn't include claims that were appealed and eventually paid." See report for more.
- However, when you include all types of plans, a survey for a similar time period suggests that estimates of 17-19% denial rates overall do not reflect coverage on resubmission or appeal. Per that survey, 12% of the 17% initially denied per that survey were covered after the first appeal, leaving 5% denied more than once.
Other things to know -
- From a KFF report on 2021 data, claim denial rates for in-network claims across all commercial insurance (includes employer & individual, not just individual/ marketplace) ranged from 2% to 49%, depending on company.
- "In 2021, 41 of the 162 reporting issuers had a denial rate of less than 10%, 65 issuers denied between 10% and 19% of in-network claims, 39 issuers denied 20-29%, and 17 issuers denied 30% or more of in-network claims. (Figure 2)"
- "Issuers that report denying one-third or more of all in-network claims in 2021 included Meridian Health Plan of Michigan, Absolute Total Care in South Carolina, Celtic Insurance in 7 states (FL, IL, IN, MO, NH, TN, TX), Ambetter Insurance in 3 states (GA, MS, NC), Optimum Choice in Virginia, Buckeye Community Health Plan in Ohio, Health Net of Arizona, and UnitedHealthcare of Arizona."
Why denied:
- Referring back to the 2023 ValuePenguin article, 48% of denials are bc the provider failed to get the required prior authorization from the insurer. "Not getting prior authorization is the top reason why health insurance claims are denied."
- Reasons: Why insurance doesn't cover hospital bills and medical claims (based on Experian's 2022 State of Claims Report, which was relied on by the ValuePenguin article)
Reason | Rate |
---|
No prior authorization from insurance company | 48% |
Doctor was not covered by plan | 42% |
Billing code issues | 42% |
Claim was not submitted before deadline | 35% |
Patient information was not accurate | 34% |
Claim had missing or inaccurate info | 33% |
Not enough staff to keep up | 33% |
Plan changed what drugs were covered | 27% |
Insurance policies changed | 27% |
Insurance procedures changed | 26% |
Medical services not grouped correctly | 22% |
Medical service not covered | 19% |
- For newer data: Here's a link to the summary of the 2024 SoC report, which you have to request - short version: it's gotten worse per providers, though reasons for that include both insurer and provider issues: the "top three reasons for denials are missing or inaccurate data, authorizations, inaccurate or incomplete patient info. In short? The problem is bad data."
- Also to know, claim coverage and availability of care are not the sane thing. There's also a difference between prior authorization and claims payments. The provider decides if it will provide care to patients who do not have approved insurance claims. (And if they're in-network and screw up the prior authorization, that's generally their responsibility; if it's out-of-network, that's likely going to be the insured's responsibility.)
- All that said, per the 2024 Experian SoC, [unclear if initial or final] industry denials rose 31% from 2022 to 2024, per the survey in that report of provider billing/claims staff.
...
As for UHC, last week they
issued a media advisory referencing overall claim denial rates. Per InsuranceBusiness magazine, "UnitedHealthcare said it approves and pays about 90% of medical claims upon submission, and that around 0.5% of the claims that required further review are due to medical or clinical reasons."
Original advisory.
Separate fact sheet/ statement:
As of December 13, 2024
UnitedHealth Group today provided the following information regarding UnitedHealthcare’s medical claims approval rate:
- UnitedHealthcare approves and pays about 90% of medical claims upon submission.
- Of those that require further review, around one-half of one percent are due to medical or clinical reasons.
- About half of those not paid initially are due to administrative errors, such as missing documentation, which can be corrected.
- The majority remaining are due to factors such as an individual not having insurance coverage with UnitedHealthcare or duplicate claims submissions.
- Any other numbers being discussed in some quarters purporting to be the UnitedHealthcare approval rate are wrong.
Salty. Note this is likely including all types of plans (government-based plans have lower denial rates), and I'm certain there's some definitional bullshit happening, but it is worth noting, especially given that the widely-cited statistic never flies around with all the relevant methodological info attached.