News: ACA marketplace plans denied nearly 17% of in-network claims in 2021, research finds

According to a brief recently released by Kaiser Family Foundation, health insurers on the Affordable Care Act (ACA) marketplace denied an average of 16.6% of in-network claims in 2021. Lack of prior authorization or referral significantly accounted for 3.6 million (8%) of the 44.7 million reasons reported for non-group qualified health plans (QHPs) denying the claims, reported HealthLeaders.

Researchers analyzed CMS data on claims denials for QHPs, finding 291.6 million in-network claims received total between the insurers in 2021 and 48.3 million of those (16.6%) denied, with denial rates ranging from 2% to 49%. From the data they found 41 insurers had a denial rate of less than 10%, 65 insurers denied between 10% and 19%, 39 insurers denied between 20% and 29%, and 17 insurers denied 30% or more.

The health plans that reported denying 30% or more of claims were Meridian Health Plan of Michigan, Absolute Total Care in South Carolina, Optimum Choice in Virginia, UnitedHealthcare of Arizona, Health Net of Arizona, Buckeye Community Health Plan in Ohio, Celtic Insurance in seven states, and Ambetter Insurance in three states. Among the 44.7 million reasons health plans reported for denying the claims, “lack of prior authorization or referral” accounted for 3.6 million (8%), followed by “excluded services” at six million (13.5%), and “medical necessity reasons” at 920,000 (2%).

The lack of required transparency in coverage data reporting by other non-group plans or employer-sponsored plans has in part hindered hospitals and health systems in their attempts to improve denials, the researchers stated.

“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,” they stated in the brief. “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.”

Editor’s note: To read HealthLeaders’ coverage of this story, click here. To read the Kaiser Family Foundation brief, click here.