A new survey by KFF highlights the problems people have with their health insurance, with 60% of insured adults saying they have experienced problems, including denied claims and appeals, and inadequate networks. The type of insurance matters, with those with Medicare or Medicaid faring better than those with other health insurance.
Some 18% of all insured respondents said they had experienced a denied claim in the past year, with those with employer-sponsored insurance more than twice as likely to report a denied claim as those with Medicare. Unsurprisingly, the likelihood of denied claims increased as people used more services; 27% of people with 11 or more provider visits reported denied claims, compared to 14% of those with 2 or fewer visits. People who identify as LGBT were much more likely to report a denied claim – 30 per cent versus 17 per cent.
Denied claims put people at risk of serious health or financial problems. For example, around a quarter of those who experienced a denial said they had experienced significant delays in treatment, were unable to get recommended treatment, or experienced a decline in health. The financial impact was even more widespread, with more than half (55%) of those who experienced denials paying more than they expected.
As KFF notes, there is no way of knowing whether these claims were 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 incorrect claims.
But other data are clear: most KFF respondents with denied claims were unaware of appeals processes and did not use them. While people with Medicare reported fewer problems accessing their coverage than those with other types of insurance, we know that Medicare is still too complicated, and its appeals processes – especially for prescription drugs – can baffle even the most knowledgeable beneficiaries and advocates. Denials and appeals accounted for 29% of all calls to our national helpline in 2022.
We will continue to advocate for better prior authorisation, appeals and other processes to ensure beneficiaries have access to the coverage and care they need.
