In light of recent events, frustration over insurance claim denials has reached a boiling point for many Americans.
The targeted killing of UnitedHealthcare CEO Brian Thompson in December sparked a nationwide discussion surrounding the systemic barriers patients face with their health insurance. As troubling stories surfaced online about the struggles to secure coverage, a spotlight was placed on the complexities of the health insurance system that so many people across the political spectrum navigate.
Miranda Yaver, an assistant professor of health policy and management at the University of Pittsburgh, noted, "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."
How rising health care claim denials are hurting Americans is becoming more evident as consumers like Shelby Kinsey, a 22-year-old resident of Texas diagnosed with ALS last year, bear the brunt of these insurance struggles. Kinsey's journey to obtain coverage for Qalsody, a treatment her doctors deemed crucial for her condition, exemplifies the uphill battle many face.
"When we were first denied, we were told it was due to Blue Cross Blue Shield of Texas deeming Qalsody medically unnecessary," Kinsey stated. Her story is not an isolated case; rather, it reflects a broader pattern of individuals confronting similar hurdles within the insurance system. In her situation, she eventually appealed the denial three times with the support of her medical team at 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 continued. The emotional toll these battles take cannot be understated, but the systemic flaws persist.
Despite rising awareness about health insurance claim denials, accurately counting the number of denied claims remains challenging due to the lack of consistent reporting by insurers. Yaver remarks, "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."
The Affordable Care Act (ACA) was implemented to better clarify the coverage denial process, aiming to increase transparency. For example, health insurance companies governed by the ACA are required to provide reasons for denials, disclose information about the claims process, and allow for an established appeal process. Yet, enforcing these regulations remains an ongoing challenge.
According to a January study published by KFF, a nonprofit organization focused on health policy, approximately 73 million of the 392 million in-network claims were denied in the U.S. in 2023. This marks a significant increase from the 48.3 million claims denied out of 291.6 million in 2021. The statistics highlight a growing concern about the barriers patients face when seeking care and the mounting frustration directed toward the health insurance industry.
Notably, the vast majority of consumers do not appeal denied claims—fewer than 1% of them do. Even among those who do attempt to appeal, only 56% of appeals are upheld by insurers. This indicates a significant gap in consumer awareness regarding their rights to appeal insurance claim denials.
Kaye Pestaina, director and vice president of the program on patient and consumer protection at KFF, stated, "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." Greater acknowledgment and understanding of these rights could serve as a check against the powerful insurance carriers who currently dictate the terms of patient care.
The stories of individuals like Shelby Kinsey illuminate the urgent need for reforms within the health insurance landscape. Increased public awareness around consumer rights and insurance claim processes can empower patients to fight back against unjust denials. Access to essential treatments should not be a struggle. It is crucial for stakeholders, from healthcare providers to policymakers, to advocate for changes that prioritize patient needs and well-being over profits.
Navigating the health insurance system may be complex, but more robust support structures and education could lead to better outcomes for those in need of care. As the dialogue progresses in the aftermath of tragedies like the killing of Brian Thompson, it becomes increasingly clear that lasting change is necessary. Patients should no longer be forced to battle their own insurance companies for the care they need. The time to act is now.