Denied insurance claims are problem for nearly 20% of insured adults, survey finds

About 6 in 10 adults experience denied claims, network inadequacy or preauthorization delays when using their health insurance, a new KFF survey found. The survey delved deeper into a few of the challenges surrounding denied claims.

Eighteen percent of insured adults experienced denied claims in the past year, which the survey defined as incidents in which insurance did not pay for care that patients received and thought was covered. Several groups of people were more likely to have had their claims denied:

• The problem was somewhat more common among people with employer-sponsored insurance (21%) or Marketplace insurance (20%) and less so among people with Medicare (10%) or Medicaid (12%).
• Among high users — patients who had more than 10 provider visits in the past year – 27% experienced a denied claim. By contrast, smaller shares of patients who had fewer than three provider visits in a year experienced a denied claim.
• About 1 in 5 insured adults who used emergency room or mental health services said they had a denied claim.
• People who identify as LGBT are nearly twice as likely to experience denied claims compared to other consumers (30% vs. 17%).

Difficulty understanding aspects of their health coverage was reported more often among consumers who experienced denied claims compared to others. A majority of consumers who experienced denied claims reported difficulty understanding what their health insurance covers (65%); what they will owe out of pocket (57%); and their explanations of benefits (52%). It is not clear whether these challenges contribute to claims being denied or whether denied claims compound the confusion consumers otherwise experience in understanding their coverage.

Read more: Denials of health insurance claims are rising: Are algorithms to blame?

Consumers who experienced denied claims were much more likely to also have encountered other problems using their coverage in the past year. On average, insured adults with denied claims experienced about four different types of insurance problems in a year. About 8 in 19 consumers with denied claims took some action to try to resolve the biggest problem they had with their insurance, such as calling the insurance company or asking their doctor or a friend or family member for help, and 15% filed a formal appeal. Among insured adults who reported insurance problems in the past year, half said the biggest problem they had was solved to their satisfaction.