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Denials of Health Insurance Claims Are Rising: Are Algorithms to Blame?

Insurers appear increasingly likely to employ computer algorithms or people with little relevant experience to issue rapid-fire denials of claims—sometimes bundles at a time—without reviewing the patient’s medical chart.

By Elisabeth Rosenthal | June 09, 2023 at 08:59 AM
Stock photo: Insurance claims form. Credit: sitthiphong/stock.adobe.com

Millions of Americans in the past few years have run into this experience: filing a health insurance claim that once might have been paid immediately but instead is just as quickly denied. If the experience and the insurer’s explanation seem arbitrary and absurd, that might be because companies appear increasingly likely to employ computer algorithms or people with little relevant experience to issue rapid-fire denials of claims—sometimes bundles at a time—without reviewing the patient’s medical chart. A job title at one company was “denial nurse.”

It’s a handy way for insurers to keep revenue high—and just the sort of thing that provisions of the Affordable Care Act (ACA) were meant to prevent. Because the law prohibited insurers from deploying previously profit-protecting measures, such as refusing to cover patients with pre-existing conditions, the authors worried that insurers would compensate by increasing the number of denials.

And so the law tasked the Department of Health and Human Services (HHS) with monitoring denials by both health plans on the Obamacare marketplace and those offered through employers and insurers. It hasn’t fulfilled that assignment. Thus, denials have become another predictable, miserable part of the patient experience, with countless Americans unjustly being forced to pay out of pocket or, faced with that prospect, forgoing needed medical help.

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