I think we need more thorough analysis. Are the denied claims denied in error? The appeals success rate probably indicates that most of the appealed denied claims were denied in error... but appealed claims are a biased sample of denied claims, so it doesn't tell us much about the overall denied claims.
In my experience, I've seen some denied claims, because the provider submitted a wrong code. Then the provider submits a new claim with the correct code and it goes through.
Given the proliferation of plans, and their sometimes conflicting requirements on medicial coding, I could see that being a big driver of denials increasing over time. As well as a driver of increased administrative costs for providers and insurance companies.
"A key congressional committee asked insurance giant Cigna on Tuesday to provide corporate documents so that lawmakers can examine the company’s practice of denying health care claims without ever opening a patient file."
From the patient’s point of view, it all looks the same. Treatment that should be covered gets denied.
It sounds like the insurance companies have a strong incentive to make their coding and requirements as complicated as possible to increase the error rate so they can deny coverage. I don’t think they should get a pass for those denials.
I don't doubt that numerous doubly legitimate claims are denied.
What I want is a sense of what the breakdown of the denied claims.
Ex: company sends a list of all denied claims. Auditor picks 100 randomly, gets the files for each and researches those denials to classify the denial as reasonable or not and whatever other categories apply.
In my experience, I've seen some denied claims, because the provider submitted a wrong code. Then the provider submits a new claim with the correct code and it goes through.
Given the proliferation of plans, and their sometimes conflicting requirements on medicial coding, I could see that being a big driver of denials increasing over time. As well as a driver of increased administrative costs for providers and insurance companies.