It pays to challenge coverage denials and medical bills: Fifty percent of adults who challenged coverage denials reported success in getting some or all denied services approved. Similarly, more than one-third (38 percent) of those who disputed medical bills saw their balances reduced or eliminated.
New research from the Commonwealth Fund finds that many insured, working-age Americans receive surprise medical bills and coverage denials for doctor-recommended care.
The Commonwealth Fund survey, conducted by SSRS from April 18 through July 31, 2023, included a random, nationally representative sample of 7,873 adults ages 19 and older living in the continental United States. The brief, Unforeseen Health Care Bills and Coverage Denials by Health Insurers in the U.S., focused on 5,602 adults under age 65 who were insured at the time of the survey. It examines how frequently insured, working-age adults are denied care by insurers, how often they are billed for services they believed were covered, and their experiences challenging such bills or care denials.
Researchers found that close to half (45 percent) of insured, working-age adults in the United States have received a medical bill or copayment in the past year for a service they thought should have been covered by their insurance. One in five (17 percent) were denied coverage by their insurer for a doctor-recommended service. Among those who reported billing errors or coverage denials, fewer than half challenged them, mostly because they weren’t aware they had the right to do so.
Among the key findings:
It pays to challenge coverage denials and medical bills: Fifty percent of adults who challenged coverage denials reported success in getting some or all denied services approved. Similarly, more than one-third (38 percent) of those who disputed medical bills saw their balances reduced or eliminated.
Challenges to coverage denials and medical bills are particularly successful for people enrolled in Medicare and Medicaid: Among Medicare recipients, 61 percent had bills reduced or eliminated after challenging them, while 46 percent of Medicaid beneficiaries achieved the same result.
Knowledge about rights to appeal billing errors is lacking: Among those who did not challenge their billing errors, over half (54 percent) said it was because they were not sure they had the right to do so. This uncertainty was most prevalent among people with low and moderate incomes, those under age 50, and Hispanic respondents. Younger individuals, particularly those ages 19–34, were most likely to be unaware of their rights, with 60 percent not knowing that they could challenge a bill. Additionally, those under 50 also were the most likely to be unsure of who to contact to address billing errors.
Worsening health conditions often result of coverage denials: Coverage denials led to delays in care for almost 60 percent of those affected, with half (47 percent) reporting worsened health conditions as a result.
To ensure patients can access the care they need, study authors advice the following policy interventions to improve consumer protections:
- Enhanced monitoring of claim denials: The U.S. Department of Health and Human Services could better fulfill the requirements of the Affordable Care Act (ACA) to monitor rates of claim denials in all commercial insurance plans, including those offered through the marketplaces and individual market, as well as group plans offered by employers and insurers.
- Stronger accountability measures: Policies that penalize insurers who repeatedly wrongfully deny coverage or send erroneous bills could help mitigate the problem. Public reporting of these incidences would also foster greater accountability and incentivize insurers to limit such practices.
- Heightened consumer awareness: Enhancing state or federal consumer information systems could help increase public awareness of an individual’s right to appeal insurance decisions, and establishing consumer support systems could simplify the appeals process.
Source : Rise Health
