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Denied Medical Claims Most Likely with Private Insurance & Rarely Resolved

October 1, 2023

Summary: This national survey finds that 21% of privately insured individuals had claims denied in the last year, on top of a similar frequency of denied or delayed prior authorizations. Those with other insurance problems (like high drug copays) had more denials, suggesting flawed insurance. Just 29% of denials were resolved.

Consumer Survey Highlights Problems with Denied Health Insurance Claims
KFF
Sep 29, 2023
By Karen Pollitz et al

An earlier KFF survey of adults with health insurance found that roughly 6 in 10 insured adults experience problems when they use their insurance. Problems studied include denied claims, network adequacy issues, preauthorization delays and denials, and others. … This Data Note takes a closer look at insured adults who said that in the past year, insurance did not pay for care that they received and thought was covered: a “denied claim.”

Comment by: Jim Kahn

This important analysis documents the extent and shape of claims denials. Here are the key points:

Figure 1: Almost 1 in 5 insured adults had at least one claim denied in the last year. Those with private insurance had more denials.

Figure 4: Individuals with other insurance problems – like the 16% with prior authorization denials or delays, or the 23% with drug payment issues, or the 27% with low insurance payments – were far more likely (as high as 76%) to experience claims denials. This suggests that some insurance is failing way short on multiple measures of financial protection.

Figure 5: Only 29% of those with denied claims had their major insurance problem resolved. As the full report indicates, many people don’t understand the denial rules or how to appeal.

If you want further insights, read the full report.

It’s no wonder that 40% of Americans have significant medical debt with the combined high prevalence of claims denials, prior authorization denials, and high cost-sharing.

Needless to say (but I do like to say it), single payer would greatly simplify and largely eliminate these problems.

About the Commentator, Jim Kahn

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Jim (James G.) Kahn, MD, MPH (editor) is an Emeritus Professor of Health Policy, Epidemiology, and Global Health at the University of California, San Francisco. His work focuses on the cost and effectiveness of prevention and treatment interventions in low and middle income countries, and on single payer economics in the U.S. He has studied, advocated, and educated on single payer since the 1994 campaign for Prop 186 in California, including two years as chair of Physicians for a National Health Program California.

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