A report from the California Nurses Association/National Nurses United charges that health insurers in California denied 26 percent of all claims submitted through the first nine months of 2010.
For the first three quarters of 2010, seven California insurance companies rejected 13.1 million claims, slightly below the 26.8 percent denial rate for 2009. The findings by CAN/NNU's research arm, the Institute of Health and Socio-Economic Policy, is based on data from the California Department of Managed Care.
The rejections "demonstrate one reason medical bills are a prime source of personal bankruptcies, as doctors and hospitals will push patients and their families to make up what the insurer denies," said CNA/NNU Co-President DeAnn McEwen.
According to the study, claims denial rates by leading California insurers for the first three quarters of 2010 were:
- PacifiCare – 43.9 percent;
- Cigna – 39.6 percent;
- Anthem Blue Cross – 27.3 percent ;
- HealthNet – 24.1 percent;
- Blue Shield – 21.9 percent;
- Kaiser Permanente – 20.2 percent; and
- Aetna – 5.9 percent.
Cigna, which denied 40 percent of claims, showed the biggest increase from 2009, increasing its rejection rate by 5.3 percent. Kaiser Permanente accounted for the biggest drop, a one-year decline of 7.4 percent.
CNA/NNU research director Don DeMoro said the insurers fail to distinguish between "eligible" and "ineligible" claims denied in data they provide to the state, which would allow for a more thorough analysis of claims data beyond the rate of denials. Under current industry standards, insurers can choose from a broad list of ineligibility criteria offered by the state, including disputes over contracts, interest or late payments, benefits "not covered" and court disputes.
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DeMoro called on the state to require more transparency in reporting. If further national reform is not forthcoming, he said, individuals and employers alike should "have access to such data to aid them in determining the best value for their money and the best care for all concerned."
"The grave and potentially irreparable nature of the risk to patients subject to unfair claims denials cannot be overstated and certainly justifies the minimal cost to managed care organizations to provide accurate and meaningful claims denial reports," DeMoro said.