It could also make more transparent trends in the incidence and handling of claims for surprise medical bills, now protected under the No Surprises Act. For example, transparency data could be helpful in oversight of compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA), revealing how or whether claims denial rates differ for behavioral health vs other services. Data are to inform regulators and consumers about how health plans work in practice.
The Affordable Care Act (ACA) requires transparency data reporting by all non-grandfathered employer-sponsored health plans and by non-group plans sold on and off the marketplace. In 2020, consumers appealed just over one-tenth of 1% of denied in-network claims, and insurers upheld most (63%) of denials on appeal. Most plan-reported denials (72%) were classified as ‘all other reasons’, without a specific reason.Īs in our previous analysis of claims denials, we find that consumers rarely appeal denied claims and when they do, insurers usually uphold their original decision. Among 2% of claims identified as medical necessity denials, 1 in 5 were for behavioral health services. Of denials with a reason other than being out-of-network, about 16% were denied because the claim was for an excluded service, 10% due to lack of preauthorization or referral, and only about 2% based on medical necessity.
Insurer denial rates varied widely around this average, ranging from less than 1% to more than 80%.ĬMS requires insurers to report the reasons for claims denials at the plan level. We find that, across insurers with complete data, about 18% of in-network claims were denied in 2020. Data were reported by insurers for the 2020 plan year, posted in a public use file in 2021, and updated in 2022. In this report, we analyze transparency data released by the Centers for Medicare and Medicaid Services (CMS) on claims denials and appeals for non-group qualified health plans (QHPs) offered on.