The big health insurers are destroying our health care system, while profiting wildly. They cannot rein in costs, so Americans with insurance often cannot afford their care. Moreover, the insurers don’t appropriately reimburse physicians and hospitals for the services they deliver. Jeff Lagasse reports for Healthcare Finance on a new report revealing the increasing rate of claims denials health care providers are facing.
In his review of The State of Claims 2024 report by Experian, Lagasse points out that providers do not have the technology to contest insurers’ claim denials efficiently. The report also focuses heavily on provider concerns about insurer preauthorization rules and policy changes that prevent them from getting paid appropriately.
Our government allows corporate health insurers to hold all the cards. They decide what health care services to pay for and when, second-guessing treating physicians on what services are medically necessary. And, they are rarely accountable for failing to cover services they are supposed to cover or for delaying payment. Rather, they are accountable to Wall Street to increase profits, which creates a powerful incentive for them to deny and delay care and provider reimbursements.
Policy changes, claims denials and payment delays are three ways insurers are increasingly profiting at the expense of providers:
- 77 of providers say that insurer policy changes are occurring more frequently.
- 73 percent say that insurers are denying claims more frequently.
- 67 percent say that insurers are delaying payment more often.
Nearly four in ten providers (38 percent) say that insurers are denying claims ten percent of the time or more. More than a third of the time, insurers refuse to authorize care. The rest of the time, insurers claim that data is missing from provider claims.
The rate of Medicare Advantage denials is increasing with each passing year. The Kaiser Family Foundation recently reported that in 2022, Medicare Advantage insurers denied 7.4 percent of prior authorization requests, up from 5.8 percent in 2021 and 5.6 percent in 2020. It’s no wonder that this year alone more than 24 health systems have cancelled their Medicare Advantage contracts.
Lagasse cites a 2017 report revealing that health care organizations several years ago lost $262 billion on claim denials out of $3 trillion in claims submitted, in a single year. After appealing, at a cost of $8.3 billion, the providers recouped 63 percent of that money. Insanity.
Maybe AI can deliver greater efficiencies for health care providers and increase their revenues, as some suggest. But, you have to imagine that the insurers will always be at least one step ahead.
Here’s more from Just Care:
- Medicare Advantage plans continue to endanger hospitals and patients
- 24 health systems drop their Medicare Advantage contracts
- Louisiana: Medicare Advantage denials harm patients, while gouging taxpayers
- OIG finds widespread inappropriate care denials in Medicare Advantage
- Corporate health insurers use NaviHealth algorithms to deny care in Medicare Advantage plans
Leave a Reply