CareSource denied 17 percent of in-network claims, below national average

New federal data gives a glimpse of how many in-network claims are being denied by Ohio insurance companies selling Affordable Care Act marketplace plans.

About 17 percent of Dayton-based CareSource’s claims for in-network care were denied in 2017, according to new federal data.

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This puts its denial rate among the lowest in the state. About 20 percent of in-network claims were denied by Ohio insurance plans and the national average was 19 percent.

What does this mean for consumers? Kaiser Family Foundation, which analyzed the data, said more information is needed to understand what these denial rates mean.

For example, the denial rates do not provide information about why a claim was denied, making it difficult to assess why denial rates vary so much across insurers.

Some of these claims are not paid by CareSource because they are not covered by their plan, such as cosmetic procedures, and others might be denied because they are duplicates, said David Finkel, CareSource executive vice president of markets.

“Being a good steward of our members’ money in the aggregate, it wouldn’t be appropriate for us to reimburse for a service that clearly is not part of the member’s policy,” Finkel said.

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He said CareSource tracks its denial rate, and if it suddenly changed that would trigger research into the root cause.

“We use it as an early warning, but we have no goal as a number that we’re expecting to hit,” Finkel said.

There’s a wide range in how many claims were denied by different insurance companies across the U.S. Some reported denial rates as low as 1 percent and others had rates higher than 40 percent.

Consumers can appeal denials, but few do. Consumers appealed less than one-half of one percent of denied claims, and issuers overturned 14 percent of appealed denials, Kaiser reported.

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