Healthcare Finance News February 3, 2025
Reasons include prior authorization or referral, excluded services and administrative issues, KFF finds.
Insurers of qualified health plans (QHPs) sold on Healthcare.gov denied an average of 20% of all claims in 2023 – 19% of in-network claims and and 37% of out-of-network claims, finds a new KFF survey.
The in-network denial rate ranged widely, with significant variation by insurer and by state from 1 to 54%.
Even though information on the reasons for in-network claims denials was scant, the most common reason cited by insurers was “Other” at 34% followed by administrative reasons (18%), excluded service (16%), lack of prior authorization or referral (9%), and only 6% based on lack of medical necessity.
Consumers rarely appeal denied claims, according to...
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