Calif. Nurses Association Says Health Plans Denied 26% of Claims Last Year

California's largest health insurers denied an average of one in four claims during the first three quarters of last year, according to a new report by the California Nurses Association/National Nurses United, KPBS' "KPBS News" reports.

CNA/NNU said the report is based on data that health insurers provided to state regulators (Goldberg, "KPBS News," KPBS, 2/1).  The Institute of Health and Socio-Economic Policy, CNA/NNU's research arm, conducted the study.

Key Findings

According to the report, seven health plans denied 26% of all submitted claims -- or 13.1 million claims -- during the first three quarters of 2010. The figure is a slight decrease from the 26.8% claim denial rate for 2009.

For the first three quarters of 2010, the claim denial rates for California's leading insurers were:

  • 43.9% for PacifiCare;
  • 39.6% for Cigna;
  • 27.3% for Anthem Blue Cross;
  • 24.1% for Health Net;
  • 21.9% for Blue Shield of California;
  • 20.2% for Kaiser Permanente; and
  • 5.9% for Aetna.

The report found that Cigna showed the biggest one-year increase in its claim rejection rate, which jumped by 5.3% from 2009. Kaiser Permanente had the largest one-year decline in its claim denial rate, which dropped by 7.4% from 2009.

Accounting for Eligibility of Claims

Don DeMoro, CNA/NNU research director, said insurers did not distinguish between "eligible" and "ineligible" claims denied in the data they provided to the California Department of Managed Health Care. DeMoro said such information would have allowed for more thorough analyses of the claims data (Anderson, Healthcare Finance News, 2/1).

Health insurers said they pay most eligible claims. They added that some claims might be denied if they involve services that are not covered benefits or patients that no longer are members of a plan ("KPBS News," KPBS, 2/1).
Robert Forster
Mr. Weiss, it is obvious that you have not managed a healthcare claims payment operation. In the end, claims deny because the plan was billed for something that is not a contractual benefit or the claim is submitted improperly. These are provider responsibilities and in ALL plans painfully detail how to submit a proper HIPAA compliant bill. A better metric is the % of properly billed and submitted claims that are paid within 30 days of billing. Currently, Medicare, Medicaid, and Calif. payers are performing >90% in 30days. The wastebasket term "denied" us meaningless re: performance or where the process is suboptimal. If a physician submits a claim without a patient name, it is denied. Is that the payers' responsibility? Unless you know the process, I would not comment. A claimless system would eliminate this bureaucracy that causes much inefficiency from untrained personnel. Rob MD
Robert Weiss
Teachers know that when the majority of a class fails an exam, that this may be an indication that the teacher was not getting the material across properly or that the exam was faulty. May I suggest to Dr. Foster that perhaps the instructions given by some insurers to patients and billers might be inadequate and that may explain the high rate of denials? But in the end, whether the denials are due to willfull desire to maximize profits or inadequate billing and claim instructions, the solution lies with the insurers and not with the patient or the provider who are the ultimate sufferers of the denials.
Ace ReDeer
To echo Mr. Forster's point, the responsibility for an accurate claim payments rests across all those involved - the patient understanding the plan in which they enrolled, including network inclusions; the doctor AND nurses who accurately code the procedure; and the insurance company to pay according to the providers contract.
Robert Forster
The nurses and their unions should be embarrassed to release a poorly researched and written report to the press to sensationalize exactly what? Their numbers taken from CDMC and CDI are crude apples and oranges and include "denied" claims for ALL reasons: 1. Pacific care gets claims when they should not be receiving most--provider error 2. Patients do not have their insurance-not eligible 3.Claim Form is incomplete or completed incorrectly as required by law 4. Claims codes used are incorrect for serverice rendered 5. Claim has contradictory information 6. Required claim attachments not attached 7. There are hundreds of reasons why claims are denied until submitted correctly and not suspended for fraud or manual pricing. Given that nearly all governmental/private plans meet prompt pay regulations, the numbers cited are at best misleading and worse purposefully politically misprepresented. Hatti, Payers do not deny claims if medically necessary by disease category. MD
Robert Weiss
This agrees with my experience as a lymphedema patient advocate. Not only does PacifiCare deny claims for medically required lymphedema treatment and compression garments, which are covered by statute and by CMS Benefit Policy Manual as "prosthetic devices", but they will fight every ALJ loss up to the Medicare Appeals Council, and then require a subscriber to appeal denials of subsequent purchases of replacements even though Medicare regulations cover replacements. Each appeal ties up the patient's funds for at least 2 years.

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