Dive Brief:
- New data from California suggests that when consumers challenge a service their insurer did not want to pay for, they win about half of the time.
- Before the ACA, no standard process for appealing denied claims existed. But the ACA allows all consumers to appeal any denied service to a third party, like a state insurance department.
- Data from the California Department of Managed Health Care demonstrate that consumer appeals from 2006 to 2012 for Kaiser Permanente had an average success rate of 56%. Success rates were similar with other large insurers.
Dive Insight:
According to insurance industry trade group America's Health Insurance Plans, insurers deny about 3% of claims. But if consumers successfully challenge more than half of those denials, it brings into question the reasons health plans are denying claims. Of course, health plans have to deny claims that they genuinely believe don't fit within the policy limits, but these numbers suggest that there's also some foot dragging going on.