How Rising Health Care Claim Denials Are Hurting Americans (Video)

By Anuz Thapa

The targeted killing of UnitedHealthcare CEO Brian Thompson in December became a turning point in the public’s growing frustration with the health insurance industry. People began sharing stories online about how insurers denied them coverage, upending their lives.

“In the aftermath of the killing of the CEO of UnitedHealthcare, we have seen a nationwide conversation about health insurance barriers, from delays to denials to just general patient frustrations by everyday Americans from across the political spectrum,” said Miranda Yaver, an assistant professor of health policy and management at the University of Pittsburgh.

One such patient is Shelby Kinsey, a 22-year-old Texas resident who was diagnosed with ALS last year. She fought her insurer, Blue Cross Blue Shield of Texas, to secure approval for Qalsody, which her doctors said was the most effective treatment for her form of ALS.

“When we were first denied, we were told it was due to Blue Cross Blue Shield of Texas deeming Qalsody medically unnecessary,” Kinsey said. “We ended up appealing the decision three times with the help of our medical coordinator at the Baylor College of Medicine.”

“It honestly shocked me how difficult the process was to get approval for a life-preserving medicine for a disease that doesn’t have many options,” she added.

CNBC reached out to Kinsey’s insurance provider for comment, but Blue Cross Blue Shield of Texas said it “does not discuss member issues with the media.”

Despite numerous headlines and reports pointing to a rise in health insurance claim denials, the system’s fragmented nature makes it hard to get an exact count.

“It can be difficult to estimate exactly how many claims are denied in a given year by health insurers because not all health insurers report this data. But there are a few things that we do know,” Yaver said. “The Affordable Care Act did a few things to try to help make more transparent this really complex insurance process of coverage denials.”

She said when insurance companies that the Affordable Care Act regulates are denying patients, they have to give the reason and disclose information about the denial, and there also has to be an appeal process.

“But as is the story of a lot of American law and policy, a lot of this comes down to enforcement,” she added.

Using the limited data, KFF, a nonprofit organization focused on health policy, published a January study showing that 73 million of 392 million in-network claims were denied in the U.S. in 2023. In 2021, 48.3 million of 291.6 million in-network claims were denied.

Notably, most consumers don’t appeal denials: Fewer than 1% did, and insurers upheld 56% of those appeals.

“One thing that we’ve seen in some of the survey work we have done from surveying consumers across different insurance types is that they simply don’t know that they have an appeal right,” said Kaye Pestaina, director and vice president of the program on patient and consumer protection at KFF. “If appeals were used more often, it might operate as a check on carriers. But from what we can see now, so few are appealed, so it’s not operating as a check on.”

Watch the video to explore the rise in claim denials, how Americans can challenge insurance companies and the current state of health care in the U.S.

This article originally appeared here and was republished with permission.