Get the facts: How many claims are denied?
Open a newspaper, turn on the nightly news, or scroll through your social feed, and you’re likely to come across conversations about the challenges facing our health care system. While these conversations are important, they’ve also revealed there’s a lot of confusion surrounding the health care system, and for good reason – it’s very complex.
In this series of articles, we’re setting out to debunk some of the most common myths and misconceptions about health care and health insurance. Our goal is to clear up the confusion and provide the facts about how the health care system works so we can identify solutions to make it better.
While it may seem like claims denials are prevalent, in reality, the vast majority of Americans’ experience is simple and straightforward.
When it comes to their experience with the health care system, having seamless access to the care they need and being able to afford that care are at the top of many Americans’ priority lists. So it’s no wonder that having a claim denied is something no one wants to go through. Fortunately, most Americans never do.
At UnitedHealthcare, we approve and pay 90% of claims shortly after they’re submitted. The remaining 10% go through an additional review process.
- Eligibility: The most common reason a claim might fall into this category is because there’s a possibility the patient is not actually a UnitedHealthcare member. This situation most often occurs when someone has recently switched to a new plan but didn’t share their current health plan ID card with their provider. The review process for these claims is typically simple and straightforward. Once we’ve confirmed the patient is enrolled in one of our plans, we approve and process the claim.
- Duplicates: Occasionally providers submit multiple claims for the same treatment or service. In these cases, we collaborate with the physician or hospital to resolve these duplicate submissions, ensuring we are only reviewing one claim per treatment or service.
- Documentation and program integrity: Claims fall into this category because the provider didn’t submit all the information necessary to review the claim. In these cases, we follow up with the care provider to notify them of the issue and work to resolve it.
- Coverage: We review claims in this category to confirm that the plan sponsor – the employer, CMS or a state government – included coverage for that particular service or procedure when designing their health plan.
- Clinical: Claims in this category are reviewed to ensure the care provided aligns with evidence-based clinical guidelines. While we can’t control doctors’ treatment decisions, we believe we have an important role in ensuring our members receive safe, appropriate and high-quality care. When the treatment our members receive does not adhere to widely accepted clinical standards, we do not approve payment to the care provider. It should be noted that only about 0.5% of claims fall into this category.
After this additional review process is completed, UnitedHealthcare’s claims approval rate stands at 98% for claims for eligible members, when submitted in a timely manner with complete information, and after duplicate claims are removed. While we are proud of that number, we also know that nothing is more personal than health care and that there is a person on the receiving end of every claim denial letter. That’s why we work hard to treat these situations with care and sensitivity, explaining the member’s and provider’s options for filing an appeal and encouraging them to reach out to us if they have questions or need further assistance.
Share
