HJAR Nov/Dec 2023

HEALTHCARE JOURNAL OF ARKANSAS I  NOV / DEC 2023 31 voluntarily, would give you what their claim denial rates are, because they don’t want to attract sicker people,”saidMila Kof- man, who leads the District of Columbia’s Affordable Care Act exchange and previ- ously served as Maine’s superintendent of insurance. About 85% of people with insurance who responded to a recent KFF survey said they want regulators to compel insurers to dis- close how often they deny claims. Pollitz, who co-authored a report on the survey, is a cancer survivor who vividly recalls her own experiences with insurance denials. “Sometimes it would just make me cry when insurance would deny a claim,” she said. “It was like, ‘I can’t deal with this now, I’m throwing up, I just can’t deal with this.’” She should have been able to learn how her plan handled claims for cancer treat- ment compared with other insurers, she said. “There could be much more accountability.” In September 2009, amid a roiling national debate over health care, the Cali- fornia Nurses Association made a startling announcement: Three of the state’s six larg- est health insurers had each denied 30% or more of the claims submitted to them in the first half of the year. California insurers instantly said the fig- ures were misleading, inflated by claims submitted in error or for patients ineligible for coverage. But beyond the unexpectedly high num- bers, the real surprise was that the nurses association was able to figure out the plans’ denial rates at all, by using information researchers found on the California Depart- ment of Managed Health Care’s website. At the time, no other state or federal reg- ulatory agency was collecting or publish- ing details about how often private insurers denied claims, a 2009 report by the Center for American Progress found. The Affordable Care Act, passed the fol- lowing year, was a game changer when it came to policing insurers and pushing them to be more transparent. The law took aim at insurers’ practice of excluding people with preexisting condi- tions, the most flagrant type of denial, and required companies offering plans on the marketplaces created under the law to dis- close their prices and detail their benefits. A less-noticed section of the law demanded transparency from a much broader group of insurers about howmany claims they turned down, and it put the Department of Health and Human Services in charge of making this information pub- lic. The disclosure requirements applied not only to health plans sold on the new mar- ketplaces but also to the employer plans that cover most Americans. The law’s proponents in the Obama administration said they envisioned a flow of accurate, timely information that would empower consumers and help regulators spot problematic insurers or practices. That’s not what happened. The federal government didn’t start pub- lishing data until 2017 and thus far has only demanded numbers for plans on the fed- eral marketplace known as Healthcare. gov. About 12 million people get coverage from such plans — less than 10% of those with private insurance. Federal regulators say they eventually intend to compel health plans outside the Obamacare exchanges to release details about denials, but so far have made no move to do so. Within the limited universe of Healthcare. gov, KFF’s analyses show that insurers, on average, deny almost 1 in 5 claims and that each year some reject more than 1 in 3. But there are red flags that suggest insur- ers may not be reporting their figures con- sistently. Companies’denial rates vary more than would be expected, ranging from as low as 2% to as high as almost 50%. Plans’ denial rates often fluctuate dramatically from year to year. A gold-level plan from Oscar Insurance Company of Florida rejected 66% of payment requests in 2020, then turned down just 7% in 2021. That insurer’s parent company, Oscar Health, was co-founded by Joshua Kushner, the younger brother of former President Donald Trump’s son-in-law Jared Kushner. An Oscar Health spokesperson said in an email that the 2020 results weren’t a fair reflection of the company’s business “for a variety of reasons,” but wouldn’t say why. “We closely monitor our overall denial rates and they have remained comfortably below 20% over the last few years, including the 2020-2021 time period,” the spokesperson wrote. Experts say they can’t tell if insurers with higher denial rates are counting differently or are genuinely more likely to leave cus- tomers without care or stuck with big bills. “It’s not standardized, it’s not audited, it’s not really meaningful,”Peter Lee, the found- ing executive director of California’s state marketplace, said of the federal govern- ment’s information. Data, he added, “should be actionable. This is not by any means right now.” Officials at the Centers for Medicare & Medicaid Services, which collects the denial numbers for the federal government, say they’re doing more to validate them and improve their quality. It’s notable, though, that the agency doesn’t use this data to scru- tinize or take action against outliers. “They’re not using it for anything,” Pol- litz said. Pollitz has co-authored four reports that call out the data’s shortcomings. An upshot of all of them: Much of what consumers would most want to know is missing. The federal government provides num- bers on insurers’ denials of claims for ser- vices from what the industry calls “in-net- work” medical providers, those who have contracts with the insurer. But it doesn’t include claims for care outside those net- works. Patients often shoulder more costs for out-of-network services, ramping up the import of these denials. In recent years, doctors and patients have