California Healthline Daily Edition

Summaries of health policy coverage from major news organizations

Calif. Nurses Association Says Health Plans Denied 26% of Claims Last Year

California's largest health insurers denied an average of one in four claims during the first three quarters of last year, according to a new report by the California Nurses Association/National Nurses United, KPBS' "KPBS News" reports.

CNA/NNU said the report is based on data that health insurers provided to state regulators (Goldberg, "KPBS News," KPBS, 2/1).  The Institute of Health and Socio-Economic Policy, CNA/NNU's research arm, conducted the study.

Key Findings

According to the report, seven health plans denied 26% of all submitted claims -- or 13.1 million claims -- during the first three quarters of 2010. The figure is a slight decrease from the 26.8% claim denial rate for 2009.

For the first three quarters of 2010, the claim denial rates for California's leading insurers were:

  • 43.9% for PacifiCare;
  • 39.6% for Cigna;
  • 27.3% for Anthem Blue Cross;
  • 24.1% for Health Net;
  • 21.9% for Blue Shield of California;
  • 20.2% for Kaiser Permanente; and
  • 5.9% for Aetna.

The report found that Cigna showed the biggest one-year increase in its claim rejection rate, which jumped by 5.3% from 2009. Kaiser Permanente had the largest one-year decline in its claim denial rate, which dropped by 7.4% from 2009.

Accounting for Eligibility of Claims

Don DeMoro, CNA/NNU research director, said insurers did not distinguish between "eligible" and "ineligible" claims denied in the data they provided to the California Department of Managed Health Care. DeMoro said such information would have allowed for more thorough analyses of the claims data (Anderson, Healthcare Finance News, 2/1).

Health insurers said they pay most eligible claims. They added that some claims might be denied if they involve services that are not covered benefits or patients that no longer are members of a plan ("KPBS News," KPBS, 2/1). This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.