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What the KFF Survey Says About Denied Health Insurance Claims

Health Insurance Denied Form Showing Unsuccessful Medical Application

KFF (formerly The Kaiser Family Foundation) recently completed the KFF Survey of Consumer Experiences with Health Insurance. In a representative sampling of 3,605 insured adults in the U.S., KFF interviewed 978 adults with primary coverage through an employer (self or spouse), 885 adults with Medicare, 815 with Medicaid, and 880 people who bought coverage on their own through the Affordable Care Act (ACA) Marketplace, aka Obamacare. This sampling of people with insurance from different sources helped ensure a representative sampling of people coming from different perspectives with regard to demographic and socioeconomic factors such as education, income and health status.

The survey asked policyholders about their experience working with their insurers from a customer perspective, with questions on topics related to claims processing, denials, the adequacy of provider networks, and how successful consumers were when it came to trying to resolve problems with their insurance company.

Would you be surprised to learn that most of the people surveyed said they experienced problems with their insurance company in the past year? No? Well, would you find it surprising to find out that people with private insurance (through their employer or the ACA Marketplace) experienced claim denials about twice as often as Medicare or Medicaid? Maybe you are just hard to surprise, or you’ve had a problem or two with your insurance in the past year as well.

Here is a summary of some of the key findings gleaned from the survey, as reported by KFF.

Fifty-eight percent of respondents said that they had experienced problems with their insurance in the past year, including claim denials, problems with their provider network, and difficulty obtaining pre-authorization. Sadly, people in poorer health reported more problems than those in better health.

About half of the people who reported problems also reported that they were unable to have their issues satisfactorily resolved. The consequences for these individuals included paying more for care, experiencing a decline in health, and for 17% of the respondents, being unable to receive care recommended by their doctors due to problems with their insurance company that they couldn’t resolve.

The survey participants most in need of mental health care services or medication were the least likely to get it. A common refrain from the insurers was that the particular service or treatment needed was not covered by the policyholder’s plan.

Denied Claims Are the Worst

KFF concluded, based on the data, that among all the problems policyholders experienced, denied claims were the most challenging for consumers to solve on their own and the least likely to be resolved satisfactorily.

Eighty-four percent of consumers with denied claims tried to get their problem resolved by talking to the insurance company or trying to get help from family, friends or their doctor. Only about 15% filed a formal appeal with the insurer. The majority of policyholders were unaware of their right to appeal, and the vast majority had no idea whether some government agency might be able to assist them.

Most distressingly, people who experienced an insurance claim denial by and large suffered serious adverse consequences, including an increase in out-of-pocket costs, a delay in receiving the care they needed or not getting it all, and a deterioration in their health.

You Have Rights!

If you didn’t know it before now, let’s make it clear: if your insurance claim is denied, you have the right to appeal that denial through various means. If you are having trouble navigating the system or think you need professional help to go up against an insurance giant and come out on top, an insurance claim denial lawyer might be able to assist you and take the burden off your shoulders without charging any upfront fee. There may also be government agencies or consumer assistance programs that can answer your questions and help you file an appeal or resolve your problem. Your claim denial letter should include a reference to any such programs that exist in your area; many insurers are required by law to provide this information.

If your health insurance claim was denied, you’re not alone. Many others face the same challenges, and those who get help filing an appeal are more likely to get their claim satisfactorily resolved and get the care they need without undue delay.

A Note About KFF

KFF, as it likes to be called, was formerly known as The Kaiser Family Foundation, and before that, The Henry J. Kaiser Family Foundation. Kaiser was an American industrialist who created Kaiser Permanente to provide health care to his workers and their families. Kaiser Permanente today is an insurance giant, as well as a hospital chain and umbrella of medical groups. KFF has chosen its new name to distinguish itself from Kaiser Permanente (and also because it isn’t a foundation anymore, although it is still a non-partisan, non-profit organization focused on matters of health policy). KFF is well-regarded for its research, journalism and public health information campaigns and shouldn’t be confused with Kaiser Permanente or considered biased toward the health insurance industry or healthcare providers.

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