By NextBestFitClaim denials
Nearly one in five insured adults had a claim denied in a year. Few appeal, though many appeals succeed. Denials shift costs to patients and providers.
Evidence
- 18% of insured adults reported a denied claim (21% employer coverage, 20% Marketplace, 12% Medicaid, 10% Medicare).Sources: KFF (2023)
Who's affected
- People with ongoing or specialist care needs: Care is delayed or denied, and appeals take time.
- Doctors, nurses, and other clinicians: Providers absorb unpaid claims and appeal work.
- Health insurers, brokers, and their shareholders: Denials lower insurers' medical spending.
Under your mix of paths
- Insurers' financial incentive to pay less
- Complex, plan-specific coverage rules
Related costs
Open questions
- Who should decide what is covered: each insurer, or one public evidence-based process?
Solution paths (2)
Open a path for what it fixes, what it creates or worsens, who gains and who loses, precedents, and how it connects to other paths. See all paths as a decision tree.
Insurers publish denial rates by service, pay penalties for overturned denials, and patients get fast external appeals.
- +Claim denials
- −Requires difficult enforcement
- −Solves only part of the problem
One public set of coverage rules; payment decisions are made by a public agency with clinicians, and appeals go to an independent board.
- +Claim denials
- −Limits choice or applies one rule to every setting
- −Central coverage decisions can feel like rationing
Also addressed by paths for other problems
One public rulebook replaces each insurer's prior-authorization and denial rules. Denials still happen, but under one appeal system.
Covering any treatment shown to work rather than applying cost-per-QALY thresholds leads to fewer coverage denials.