The Kaiser Family Foundation (KFF) has released a report on claims denials and appeals in the ACA (Affordable Care Act) marketplace plans in 2023. ACA insurers denied 1 in 5 medical claims in 2023, the highest rate since 2015. UnitedHealth Group had the highest in-network denial rate.
Plans sold on HealthCare.gov denied 19% of in-network claims in 2023 and 37% of out-of-network claims for a combined average of 20% of claims. There was significant variation by insurer and by state. The most common reason for denial cited by insurers was “Other” (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. Fewer than 1% of denied claims were appealed. When they were, insurers uphold their original decision 56% of the time.
