State HMOs deny 1 in 5 claims, analysis shows
Published: 2009-09-23 14:42:17
Author: Lisa Girion | Los Angeles Times | September 3, 2009
California HMOs reject one out of five medical claims, according to an analysis by the California Nurses Assn. of data the companies submit to the state.
The analysis -- the first of its kind based on state government-collected data -- concluded that from 2002 through June 30, 2009, five of the largest insurers in the state rejected 31.2 million claims for medical care, or 21% of all claims.
The denial rates ranged from a low for Aetna of 6.5% to a high for PacifiCare of 39.6%, for the first half of 2009. Anthem Blue Cross, the state's largest for-profit health plan, and Kaiser, the state's largest nonprofit plan, each rejected 28% of claims during the first six months of this year, according to the study. And Cigna denied 33%.
"Every claim that is denied represents a real patient enduring pain and suffering," said Deborah Burger, co-president of the organization. "Every denial has real, sometimes fatal, consequences."
But insurers cautioned that claim rejections reported to regulators do not always reflect actual denials of treatment to patients. And, they said, claims may be denied for a number of legitimate reasons.
"Health plans have strict requirements and meet the letter of their contracts with their members to make sure they pay all the claims they are supposed to," said Nicole Kasabian Evans, a spokeswoman for the California Assn. of Health Plans.
California health plans pay out more than $75 billion a year in medical claims, she said. "Health plans seriously question the data, especially given that it's coming from an organization that has a long-term political goal of government-run healthcare."
Don DeMoro, director of the nurses association's research arm, said the data is publicly available. "If you don't agree with the conclusions, get out your slide rule and do your own calculations," he said.
DeMoro said the association asked for the data a couple of years ago and was told that it wasn't collected.
It wasn't until recently, he said, that researchers stumbled across it on the Department of Managed Health Care's website. In a section of "schedule G" attached to their annual financial reports, each company lists monthly totals of claims received and claims denied.
Full story
Published: 2009-09-23 14:42:17
Author: Lisa Girion | Los Angeles Times | September 3, 2009
California HMOs reject one out of five medical claims, according to an analysis by the California Nurses Assn. of data the companies submit to the state.
The analysis -- the first of its kind based on state government-collected data -- concluded that from 2002 through June 30, 2009, five of the largest insurers in the state rejected 31.2 million claims for medical care, or 21% of all claims.
The denial rates ranged from a low for Aetna of 6.5% to a high for PacifiCare of 39.6%, for the first half of 2009. Anthem Blue Cross, the state's largest for-profit health plan, and Kaiser, the state's largest nonprofit plan, each rejected 28% of claims during the first six months of this year, according to the study. And Cigna denied 33%.
"Every claim that is denied represents a real patient enduring pain and suffering," said Deborah Burger, co-president of the organization. "Every denial has real, sometimes fatal, consequences."
But insurers cautioned that claim rejections reported to regulators do not always reflect actual denials of treatment to patients. And, they said, claims may be denied for a number of legitimate reasons.
"Health plans have strict requirements and meet the letter of their contracts with their members to make sure they pay all the claims they are supposed to," said Nicole Kasabian Evans, a spokeswoman for the California Assn. of Health Plans.
California health plans pay out more than $75 billion a year in medical claims, she said. "Health plans seriously question the data, especially given that it's coming from an organization that has a long-term political goal of government-run healthcare."
Don DeMoro, director of the nurses association's research arm, said the data is publicly available. "If you don't agree with the conclusions, get out your slide rule and do your own calculations," he said.
DeMoro said the association asked for the data a couple of years ago and was told that it wasn't collected.
It wasn't until recently, he said, that researchers stumbled across it on the Department of Managed Health Care's website. In a section of "schedule G" attached to their annual financial reports, each company lists monthly totals of claims received and claims denied.
Full story