Rise in Health Insurance Claim Denials for Unusual Reasons: An Opinion

Elizabeth Rosenthal, a senior contributing editor for KFF Health News and author of An American Sickness: How Healthcare Became Big Business and How You Can Take it Back, writes about the rise in medical insurance claim denials experienced by millions of Americans in recent years. She explains how the use of computer algorithms and personnel with little relevant experience by insurance companies to process claims quickly without verifying the content of claims has become a predictable and distressing part of the patient experience, resulting in a growing number of unfairly co-paying individuals or those deprived of the medical help they need.

A recent study by the Kaiser Family Foundation (KFF) found that insurance companies were denying an average of 17% of claims made by patients enrolled in network physicians under the Healthcare Affordability Act, a provision meant to prevent insurance companies from denying coverage to patients with pre-existing conditions. The rise in denials, often based on bizarre rationales, can be partially explained by an investigation into insurance giant Cigna’s automated system, which allows medical reviewers to complete 50 cases in 10 seconds, without looking at a patient’s record, thereby allowing focus on profit rather than patient needs.

Politz, one of the authors of the KFF study, said that HHS, mandated to collect denial data from private health insurance companies and entities and release them into the public domain, had not audited the completeness of gathered data, resulting in a near-nonexistent federal oversight and the HHS not responding to requests for comment. Rosenthal calls for a mandated investigation and enforcement.

In conclusion, the rising trend of claim denials by insurance companies robs millions of Americans of the medical care they need and rightfully deserve, and as such, federal oversight and enforcement are necessary to address this issue.

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