A new survey from KFF highlights problems people have using their health insurance, with 60% of insured adults reporting that they have had issues, including denied claims and appeals, as well as network inadequacy. The type of insurance matters; those with Medicare or Medicaid fare better than those with other health coverage.
Around 18% of all insured respondents said they faced denied claims in the past year, with those covered by employer-sponsored insurance over twice as likely to report denied claims than those covered by Medicare. Unsurprisingly, the likelihood of denied claims rose as people used more services; 27% of people with 11 or more provider visits reported denied claims while 14% of those with 2 or fewer visits reported the same. People identifying as LGBT were much more likely to report a denied claim—30% vs 17%.
Denied claims put people at risk of serious health or financial problems. For example, around a quarter of those who experienced denials said they faced significant delays in treatment, were unable to receive recommended treatment, or experienced a health decline. The financial consequences were even more prevalent, with over half (55%) of those who faced denied claims paying more than they expected.
As KFF notes, there is no way to know if coverage for these claims was appropriately or inappropriately denied. They also note that people with denied claims report more difficulty understanding their coverage, which may mean they were more likely to submit erroneous claims.
But other data are clear: Most of KFF’s respondents with denied claims did not know about and did not use appeals processes. While people with Medicare reported fewer issues accessing their coverage than those with other types of insurance, we know that Medicare is still too complicated and its appeals processes—especially around prescription drugs—can baffle even the most knowledgeable beneficiaries and advocates. Denials and appeals represented 29% of all calls to our national helpline in 2022.
We will continue to advocate for better prior authorization, appeals, and other processes to ensure that beneficiaries get access to the coverage and care they need.
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