A fifth of the insurance claims of Americans trust Obamacare were rejected last year and denied access to the care of millions of people.
An analysis of Charity Charity Kaiser Family Foundation (KFF) evaluated nearly 400 million claims made to insurance companies included in the Affordable Care Act (ACA), which offers insurance to 21 million Americans with a lower income.
The researchers found around 19 percent of the claims for services in the network – of a provider who works with that insurance – was refused in 2023, a jump of 15 percent compared to the previous year.
The speed was still amazing for coverage outside the network, in which almost four in 10 claims were refused.
The team also found Blue Cross Blue Shield from Alabama, which served 3 million inhabitants, denied 35 percent of the claims, most of every insurance company included in the ACA, also known as Obamacare.
UnitedHealth Group, which was brought under fire for accusations of stopping life -saving medical care and the too much charging of patients, came in second place and refused one in three claims that was submitted in 2023 for his ACA plans in 20 states.
And Health Care Service Corporation, the fifth largest health insurer in America, denied 29 percent of the claims.
While Guidewell Mutual Holding, a subsidiary of Blue Cross Blue Shield of Florida, shot the least claims, it was still responsible for one in the eight denials.
Blue Cross Blue Shield from Alabama denied most claims of every Affordable Care Act -Insurance company in the US, a new analysis has shown
The most common reason that claims were refused were mentioned as 'other', which means that there was no clear explanation. This was the reason mentioned for one in three denied claims.
'Administrative reason', excluded services and registered people who reached their maximum coverage limit were among the most common reasons for rejected claims.
However, the researchers noticed that details were scarce, so no explanations were given.
Treatments that are considered 'not medically necessary', formed one in 20 claims. It is unclear what the treatments were for.
Despite the high percentages of refusal, the analysis showed that less than one in 100 patients appealed against their claims.
In the rare cases they did, however, insurance companies maintained their decisions more than half the time.
It is unclear how many patients had to pay for denied claims.
The findings come when more than 40 percent of Americans report that they have problems paying off their medical accounts, and about half of the insured adults are concerned about providing their insurance premiums.
ACA plans cost an average of $ 477 per month in 2024, according to data from health markets.
For the new analysis, KFF researchers analyzed 392 million claims submitted to ACA insurance companies in 2023, the latest available data.
Data is derived from public reports released by the Federal Centers for Medicare and Medicaid Services (CMS).
It did not include claims from private insurers, such as policy provided to people through their employers.
Insurance claims can be refused for various reasons, including services that are not included in a plan or a service that is considered 'not medically necessary'
In general, ACA insurance plans denied 19 percent of the total claims in 2023, an increase of 16 percent in 2022.
This was the highest percentage since 2015, in which 19 percent of the claims were refused. This yields up to 73 million claims.
In recent years, the lowest rate was 14 percent in 2018.
Blue Cross Blue Shield from Alabama received slightly more than 13 million claims in 2023 and denied 4.5 million, around 35 percent.
UnitedHealth Group, which serves 20 states that use ACA insurance plans, received 14 million claims and 4.6 million denied, a rate of 33 percent.
And Health Care Service Corporation, which serves four states that use ACA plans – Illinois, Montana, Oklahoma and Texas – received just over 25 million claims and shot 7.3 million, a percentage of 29 percent.
Centene Corporation, the largest health insurer managed by Medicaid, saw the most claims at 83 million. Of these, 11.4 million was refused, which adds to 14 percent.
Guidewell Mutual Holding, based in Florida, had the lowest denial percentage of 6.7 million of 53 million – 13 percent.
In KFF's analysis, Alabama had the highest percentage of claims with 34 percent, which is probably due to the denial percentage of Blue Cross Blue Shield of Alabama.
Oklahoma followed closely with a percentage of 29 percent and Alaska had the second most denial by 25 percent.
Of the states that were included in the analysis, South Dakota had the least denials with a percentage of six percent.
The researchers said claims can also be refused several times.
For example, if the name of a patient is played in the first claim, so that they cannot be identified, this can be re -refused after he has been corrected because of a service that is not covered.
Insurance companies also varied greatly in terms of reasons for refusal.
For example, Cignna Healthcare from North Carolina shot 30 percent of the claims because the treatment was not 'medically necessary'.
And Blue Cross Blue Shield from Arizona denied 97 percent of the claims due to a lack of prior authorization or referral.
The researchers noted that a denied claim does not mean that the insurance company will ultimately not pay the costs. A new claim can be submitted instead.
Recent research by Cornell University suggests that 100 million Americans – almost one in three – are in one form of medical debts, largely due to a lack of insurance and refused coverage.
And an estimated eight percent of Americans – 26 million – have no form of insurance.
