Knowledge Bank

Introduction Through the passing and implementation of the Patient Protection and Affordable Care Act, creation of an available health insurance marketplace took place in which all states must offer their own exchange or rely on that of the federal government. There have been policy concerns on health care access among enrollees in the Marketplace plans. One issue within this realm is the prevalence of insurance claims denials. Multiple possible explanations for these denials exist, however, a potentially alarming reason is that of providers being deemed “Out of Network”. This poses a threat to the validity or worth of insurance plans included on the marketplace and the ability for individuals to both locate in-network providers and pay for health services out of pocket. This study aimed at examining the proportion of claims denials for “Out of Network” providers and identify geographic patterns and differences in plan types. Methods Public data was used, compiled by the Center for Medicare and Medicaid services for the years 2019 through 2021 to examine the proportion of insurance claims denied due to “Out of Network” providers across the years, states, and given insurance plan types. Additionally, separate analyses were performed to understand the implications for lack of numeric information within the datasets. I conducted separate analyses. The first examined overall relevance of claims denials due to “Out of Network” providers and the other addressed the non-numeric missing data included within CMS data files. Each of these subsections then attempted to find trends observed across the three study years, determined if there are any identifiable geographic implications associated with this data, and finally identified trends amongst the different insurance types included within the marketplace. Results Overall, 5.92% claims were denied on average for reasoning of Out-of-network providers, each year. The findings revealed that the areas of the United States more disproportionately impacted are states located either in the central and southeastern regions. More denials were observed for those enrolled with either Health Maintenance Plan (HMO) or Exclusive Provider Organization (EPO) insurance plans than other plan types. I further found that there was a substantial amount of non-numeric or missing data. On average 67.92% of insurance carriers did not report data for reasons of denied claims due to out-of-network providers. This came in the form of character responses including data outside the scope of what is possible and omitted information on all states using a State-Based Health Insurance Marketplace. The non-numeric missing data varied by geographic regions and health plan types too. Discussion The magnitude of “Out of Network” denials may be explained by a number of reasons such as limited contracting with providers, and inaccurate information through the provider directories. However, patients have to bear the consequences, including delayed health services and substantial out-of-pocket costs drawn from savings to pay for the denied claims, and increased prevalence of surprise bills. Despite this knowledge learnt from my study, lack of complete quantified data hinders the public inquiries. Further analysis is needed to fully understand the scope of the issue as, in which additional years after the enactment of the Affordable Care Act will be assessed along with delving into publicly accessible state-based marketplace information. Conclusion Overall, a fair number of discernible associations were observed between claims denials for an “Out of Network” provider across the three study years, at a state level, and for certain plan types. Improvements in monitoring reasons of denied claims by the CMS system are needed to eliminate the broadened impact denied claims have on patients.