New Yorkers fought health insurance denials 41K times last year. Did complaints work?
New Yorkers filed nearly 41,000 grievances to challenge health coverage denials last year amid mounting concerns about the skyrocketing cost of medical care, drugs and insurance premiums, state data show.
Strikingly, that grievance total is about 46% higher than the average number filed annually during the five years prior, according to a USA TODAY Network analysis, suggesting current economic conditions and corporate policies are fueling more clashes over insurance coverage.
For consumers, details of those grievances, as well as thousands of other forms of health coverage complaints, offered key insights into potential systemic issues at health plans.
Further, the complaint data becomes increasingly valuable as open enrollment begins this fall and New Yorkers compare health plans. At the same time, insurance premium rates on average will rise double-digit percentages in 2024, raising the stakes.
How many insurance denials get reversed in NY?
Last year, about 10,400 grievances, or one in four cases filed by consumers and health providers, resulted in the initial insurance coverage denial being reversed.
That reversal rate of about 25% fell below the nearly 30% average over the five years prior, the analysis found, but state regulators noted there is no “ideal” reversal rate.
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Among state regulator advice on reading reversal rates for each health plan:
A low reversal rate may indicate the company’s initial decisions are correct, so fewer decisions require reversal.
But an unusually low reversal rate may indicate the company does not give appropriate reconsideration to initial decisions.
A high reversal rate may indicate a company’s grievance process is responsive to members and providers.
But an unusually high reversal rate may indicate the company’s process for making initial decisions is flawed.
The number of grievances filed may be higher for health insurance companies that actively promote the grievance process to members and providers.
In one health plan category, United Healthcare Insurance Company of New York had the lowest reversal rate at zero percent for more than 13,600 grievances.
By contrast, Oxford Health Insurance’s reversal rate of nearly 14% impacted the next-highest number of grievances, totaling about 8,500. And Healthfirst Insurance Company had the highest reversal rate (nearly 92%) for its 700-plus grievances.
How many health insurance complaints in NY?
In addition to grievances, New Yorkers filed nearly 79,000 other forms of complaints last year involving health plans in New York.
The types of filings varied from prompt pay complaints to internal and external appeals filed, with the number of complaints and reversal rates varying widely by health plan.
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Many of the complaints involved challenges to health plans’ refusal to pay for a medical service. Most cases come after the health insurance company asserted the service was experimental, investigational, not medically necessary, a clinical trial, or a treatment for a rare disease.
For further details about complaints and reversal rates for each health plan, visit the state Department of Health website at dfs.ny.gov, or call its hotline at (800) 342-3736.
This article originally appeared on Rockland/Westchester Journal News: NY health insurance: Residents challenged 41K coverage denials in 2022
