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Denials are common for those with ACA Marketplace plans

On Behalf of | Dec 28, 2022 | Denied Insurance Claims

The Affordable Care Act (ACA) was revolutionary in ensuring that many of those who previously could not afford or obtain health insurance would be able to find an affordable insurer through the ACA Marketplace.

The idea was that a person with health insurance would have much of their medical bills covered. Unfortunately, this is not happening as nearly one in five claims submitted by those with ACA Marketplace plans are denied.

Almost one in five ACA Marketplace claims denied

For those insured through an ACA Marketplace plan, health insurance denials are becoming all too common. A Kaiser Family Foundation analysis found that in 2020, approximately 18% of in-network claims for those with an ACA plan were denied.

These claims are denied for a variety of reasons. For example, approximately 16% of denied claims were due to excluded services. Lack of preauthorization or referral was cited as the reason for 10% of the denials.

The analysis found that approximately 2% of denied claims were based on medical necessity. The remaining 72% of denied claims were based on an unspecific category referred to simply as “all other reasons.”

What can you do if your claim is denied?

The amount of denied ACA marketplace claims is discouraging. Still, if your health insurance claim is denied, there are steps you can take to try to appeal the denied claim.

First, call your insurance company. The denial may have been made in error. If not, ask the reviewer who issued the denial to explain why your claim was denied.

If that does not remedy the situation, you can file a formal appeal. State your reason why your claim should have been approved. You can buttress your position with medical records and a letter from your physician.

If that does not lead to a satisfactory result, you may need to appeal to an independent third party.

There are many reasons an insurer will deny a claim. It can be challenging and frustrating to try to fight a denied insurance claim on your own. Fortunately, you can seek the advice of legal counsel familiar with denied insurance claims to help you in your pursuit.