HJAR Nov/Dec 2023

HOSPICE RATINGS 30 NOV / DEC 2023 I  HEALTHCARE JOURNAL OF ARKANSAS   commissioners gathers a more detailed, reliable trove of information. Yet, even though commissioners’ primary duty is to protect consumers, they withhold nearly all of these details from the public. ProPublica requested the data from every state’s insur- ance department, but none provided it. Two states collect their own infor- mation on denials and make it public, but their data covers only a tiny subset of health plans serving a small num- ber of people. The minuscule amount of details available about denials robs con- sumers of a vital tool for comparing health plans. “This is life and death for people: If your insurance won’t cover the care you need, you could die,” said Karen Pollitz, a senior fellow at KFF (for- merly known as the Kaiser Family Foundation) who has written repeat- edly about the issue. “It’s all knowable. It’s known to the insurers, but it is not known to us.” The main trade groups for health insurance companies, AHIP (formerly known asAmerica’s Health Insurance Plans) and the Blue Cross Blue Shield Association, say the industry supports transparency and complies with gov- ernment disclosure requirements. Yet the groups have often argued against expanding this reporting, saying the burdens it would impose on insurance companies would outweigh the ben- efits for consumers. “Denial rates are not directly com- parable from one health plan to another and could lead consumers to make inaccurate conclusions on the robustness of the health plan,” Kelly Par- sons, director of media relations for the Blue Cross Blue Shield Association, said in an email. The trade groups stress that a substantial majority of patient claims are approved and that there can be good reasons — including errors and incomplete information from doctors — for some to be denied. “More abstract data about percentages of claims that are approved or denied have no context and are not a reliable indicator of quality — it doesn’t address why a claim was or was not approved, what happened after the claim was not approved the first time, or how a patient or their doctor can help ensure a claimwill be approved,”AHIP spokesperson Kristine Grow said in a writ- ten response to questions fromProPublica. “Americans deserve information and data that has relevance to their own personal health and circumstances.” The limited government data avail- able suggests that, overall, insurers deny between 10% and 20% of the claims they receive. Aggregate numbers, however, shed no light on how denial rates may vary from plan to plan or across types of medical services. Some advocates say insurers have a good reason to dodge transpar- ency. Refusing payment for medical care and drugs has become a staple of their business model, in part because they know customers appeal less than 1% of denials, said Wendell Pot- ter, who oversaw Cigna’s communi- cations team for more than a decade before leaving the industry in 2008 to become a consumer advocate. “That’s money left on the table that the insurers keep,” he said. At least one insurer disputes this. Potter’s former employer, Cigna, said in an email that his “unsubstantiated opinions” don’t reflect the company’s business model. In a separate written statement, Cigna said it passes on the money it saves “by lowering the cost of health care services and reducing wasteful spending” to the employers who hire it to administer their plans or insure their workers. The few morsels insurers have served up on denials stand in stark contrast to the avalanche of informa- tion they’ve divulged in recent years on other fronts, often in response to government mandates. Starting last year, for example, insurers began dis- closing the prices they’ve negotiated to pay medical providers for most services. Experts say it’ll take similar mandates to make insurers cough up information on denials, in part because they fear plans with low denial rates would be a magnet for peo- ple who are already ailing. “Health plans would never do that “Refusing payment for medical care and drugs has become a staple of their business model, in part because they know customers appeal less than 1% of denials.”