A new report from the Kaiser Family Foundation has found that, from 2015-2017, 20% of all claims made by individuals covered under the Affordable Care Act, commonly known as Obamacare, have been denied. This has led to thousands of patients going “out of pocket” to cover expensive procedures or putting themselves at risk by not getting the procedures performed at all.
The report analyzed “transparency data released by the Centers for Medicare and Medicaid Services (CMS) to examine claims denials and appeals among issuers offering individual market coverage on healthcare.gov from 2015-2017.” In 2017, 19% of all health claims filed were rejected. When a claim is rejected, an individual has a right to appeal the decision. However, less than one half of a percent of individuals choose to do so. Of the few that do file an appeal, only 14% are overturned. Depending on the insurer, claim denial rates ranged from 1% to 45%.
Due to transparency limitations by insurers, there is little data to suggest why the claims were denied:
Issuers use standardized reason codes for claims adjustments and denials; without this information, one cannot distinguish claims denied for reasons of medical necessity, for example, from those denied due to an incorrect or incomplete submission. Transparency data also do not include other detail that could shed light on the nature of claims submitted and denied – for example, reporting on the types of services or dollar amounts involved.
The Kaiser Foundation, despite the limited data, did find that many of the denials were a result of clerical errors or incorrect coding.
In 2017, Ohio Obamacare claims rejection rates were just above the national average at 20.3%. 8 insurers in the state account for 97% of all state enrollment. Their denial rates are:
AultCare Insurance Company (10% denial rate)
Community Insurance Company(Anthem BCBS) (25%)
Buckeye Community Health Plan (20%)
Summa Insurance Company (43%)
Molina Healthcare of Ohio (33%)
Paramount Insurance Company (24%)
Medical Health Insuring Corp. of Ohio (13%)
Of the states with available data, Kentucky had the highest, overall, denial rates at 40.70% while Oregon had the lowest at 7.6%. This report raises serious concerns about the Affordable Care Act, just as its future is being aggressively debated in Washington DC.
As previously reported, in late March, the Department of Justice, at the behest of President Trump sent a letter to the Fifth Circut court, stating that they agreed with a lower court’s ruling that Obamacare is unconstitutional and, “Because the United States is not urging that any portion of the district court’s judgment be reversed, the government intends to file a brief on the appellees’ schedule.” Underscoring how complicated the legal matter has become, Ohio Republican Attorney General Dave Yost has announced that he will file an Amicus Brief in support of Obamacare. AG Yost did state that he felt the individual mandate was unconstitutional but opposed the repeal due to concerns over its effect on the unemployed and those with preexisting conditions.
Concurrent with these proceedings, Democratic legislation in DC are planning to introduce a series of “Obamacare fixes” in the hope of addressing the ongoing issues with the legislation while upholding its core functions.
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Andrew Shirley is a reporter at Battleground State News and The Ohio Star. Send tips to [email protected].