KFF Study on Claims Denials

The Kaiser Family Foundation (KFF) recently released a study concerning denials from insurance companies participating in the ACA exchanges. Per their analysis, among in network plans in the 2017 marketplace, they found an average denial rate of 19%. Among individual plans, denial rates ranged from extremes of 1% and 40%. KFF also found that only 14% of patient initiated appeals resulted in the overturning of a denial.

With 19% of providers’ revenue being withheld due to denials, this data indicates that denials remain a pressing problem for providers and billers. Best practices to limit denials include verifying benefits, checking for authorization/referral requirements before providing services, maintaining thorough and accurate notes, and ensuring accurate coding.

Another interesting note from the report was that patients only appealed less than 0.5% of those denials. While the ACA mandates that all patients have appeal rights, this statistic reinforces the fact that most patients have little understanding of the billing process, or their rights when dealing with their insurance. This reflects a broader problem of patients not understanding their insurance benefits in general. Accordingly, it remains up to providers and billers to educate patients on how insurance works, as well as assist them in obtaining referrals, authorizations, and filing appeals.

The study looked at nearly 230 million in network claims compiled from 180 insurance companies participating in the markets.

David Swiercz