Preventive care claim denials more common for those with greater social needs
September 27, 2024
Denial Rate by Income Bracket
Denial Rate by Race/Ethnicity
Denial Rate by Educational Level
Source: Hoagland, et al JAMA Network Open September 18, 2024
The Affordable Care Act requires that high value preventive services recommended by the US Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP), and the Health Resources Services Agency (HRSA) are available to health plan members with no cost sharing. This includes general preventive services (USPSTF), vaccinations (ACIP), and services for women’s health (HRSA). This is a core precept of value-based insurance design, where member cost share should be lower for high-value services, and higher for low-value services.
But we all know that many with insurance still end up paying for preventive care in many instances! For instance, women getting oral contraceptives might find that their pharmacy benefit manager imposes a fee for not using mail order pharmacies. Cost sharing is sometimes improperly applied to screening tests that should be fully covered.
Research published in JAMA Network Open demonstrated that those who had lower income, lower educational level, or were part of minoritized groups were statistically significantly more likely to face denials of claims for preventive services. The researchers reviewed 4 years of data from about 1.5 million people who received 4.2 million preventive services, including contraception, breast and colon cancer screening, diabetes and cholesterol screening, and wellness visits. Their database used self-identified race and ethnicity obtained from medical records, voter registration, and other publicly available sources. They followed each denial through any appeals and resubmissions.
They found that about 1.34% of total preventive services were denied overall. The three most commonly denied services were diabetes screening (3.1%), depression screening (2.8%), and contraceptive care (1.1%). Benefit denials and billing errors represented most of the denials for all services and all subgroups.
This analysis did not include some procedures that are unequivocally preventive, but where billing rules mean that insurers are not required to provide coverage without out-of-pocket costs. The researchers removed these services based on billing codes. This includes colonoscopies which are considered “diagnostic” for those with previous colon polyps or colon cancer, and mammograms which are considered diagnostic in women with a history of breast cancer. Therefore, this analysis understates the portion of those with insurance who face out-of-pocket costs for preventive services.
Implications for employers:
- Employers can query their carriers about denial rates for preventive care and encourage them to instruct their claims adjudication software to limit denials for preventive care. They can also inquire whether there is a quality assurance process in place to review denials on an ongoing basis.
- Employers can also instruct their carriers to pay for periodic mammograms and colonoscopies that are screening even in those with a history of breast or colon disease, assuming the procedure was not to address an existing condition.
- This demonstrates the importance of reporting by race and ethnicity to identify disparities. Identifying disparities can help us in our effort to achieve health equity.