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Sentences I am happy about in the Senate bill: Part II

Page 48:

The Exchange shall require health plans seeking certification as qualified health plans to submit to the Exchange, the Secretary, the State insurance commissioner, and make available to the public, accurate and timely disclosure of the following information:

(i) Claims payment policies and practices.
(ii) Periodic financial disclosures.
(iii) Data on enrollment.
(iv) Data on disenrollment.
(v) Data on the number of claims denied.
(vi) Data on rating practices.
(vii) Information on cost sharing payments with respect to any out-of-network coverage.
(viii) Information on enrollee and participant rights under this title.
(ix) Other information as determined appropriate by the Secretary.

I, for one, would like to know what percent of claims are denied by a given insurer, and whether a larger-than-average number of people are fleeing that insurer every year.

By Ezra Klein  |  December 19, 2009; 2:49 PM ET
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Agree that this is a great addition. Love your evolution to the importance of consumerism in health care. :) Wyden's folks must be rubbing off on you.

A small aside-- I hope this data is available in raw format, so that websites can be developed and incorporate the data, which are more likely to be consumer-friendly than what you see with HHS. is pretty bad.

Posted by: wisewon | December 19, 2009 3:10 PM | Report abuse

PS Agree on claims (potentially risk-adjusted) but would also suggest that the benefit side is missing, i.e. info that NCQA collects and evaluates on health plans.

Posted by: wisewon | December 19, 2009 3:13 PM | Report abuse

Yawn. A lot of this info is already available and none of it is among the top five criteria people use when selecting a plan.

Posted by: bmull | December 19, 2009 3:24 PM | Report abuse


Posted by: jkaren | December 19, 2009 3:26 PM | Report abuse

That's about the point where, if I'm an insurer, I say, "Adios, mo fos. Play your own insurance games, I'm off to the Bahamas. Have fun and Good Luck."

Posted by: msoja | December 19, 2009 3:33 PM | Report abuse

By the way, are Medicare and Medicaid required to report all that stuff?

Posted by: msoja | December 19, 2009 3:39 PM | Report abuse

bmull is right, most of this information is already made public in most states. It isn't easily accessible, true, but then some organization could have consolidated it and made it accessible, and by and large that hasn't happened. So it is unclear whether this will really have much impact. Far more important is the ability of the exchange to set the ground rules on what insurance will be offered in the exchange, and reject products if the premium is deemed unjustified.

Ezra, while I understand your curiosity about denial rates, there are two things to keep in mind:

1) this is a pretty crude measure. It's important to know which claims are being denied, and why. An HMO will typically have a higher denial rate than a PPO, because people try to get care without a referral, outside of the network, etc. That doesn't mean the HMO is behaving badly, in the sense that it is trying to be devious to breaking rules, etc., just that the rules are more stringent. That same HMO will also almost certainly pay a higher share of the total cost of care than a PPO. If you compare two PPOs or two HMOs, on the other hand, with similar benefits, and the plan with a lower premium also has a higher rate of denials, then that might raise a red flag that the cheaper policy is cheaper because a more denial-happy claims department. I don't expect too much of this.

2) Denials aren't always bad! Sometimes people (physicians or patients) try to game the system and stick other people with the cost. I have no idea what an optimum rate of denials is, and really it will depend on the local culture around medicine, but the number certainly isn't zero.

(jdhalv, formerly jd)

Posted by: jdhalv | December 19, 2009 4:11 PM | Report abuse


Your points on claims denial are fair-- but at the same time, they are exactly the same concerns physicians raise about evaluating THEIR performance. The point is, those things can be accounted for health plans and doctors-- hence my point on adjustment-- but that isn't an excuse for not providing the data. Its one data point that along with a number of others, is a reasonable set of information for more rationally selecting a health plan.

Posted by: wisewon | December 19, 2009 4:18 PM | Report abuse

msoja, "Medicare" is just a payer. The various private insurers offer plans that Medicare folks enroll in. I presume the insurers offering Medicare plans have to post the same data. In California, Medicaid is done by counties who contract with hospitals and drs or treat people at county hospitals, I believe.

Posted by: Mimikatz | December 19, 2009 5:04 PM | Report abuse

As an FYI, Ezra, the California Nurses Association put out the only study I'm aware of on this topic, using data that was basically hidden on the CA Dept of Insurance web site.

Top lines: in CA, 21 percent of claims were denied in the period studied:

Posted by: NationalNursesMovement | December 19, 2009 5:35 PM | Report abuse

wisewon, I agree. I didn't mean to suggest that the data should not be provided and made easily accessible. Just that once it is out there, one will need to develop an art to interpret it.

This will be a great new market for Consumer Reports.

Posted by: jdhalv | December 19, 2009 7:22 PM | Report abuse

Who gonna chck the correctness of all those informations? And what aree the pnalties for fraud? Once again, this looks like a great provision on paper, but most probably it will have no effect at all in reality. Insurers will put lipstick on their pig, and that's it.

Posted by: Gray62 | December 20, 2009 11:25 AM | Report abuse

The data on denials that is available now needs a lot of refinement to make it more accurate and easier to understand. As some commenters have pointed out, there are different types of denials, some more significant than others. Some denials are simply because the consumer didn't read the fine print and follow the rules; others have to do with denying care that has little to no evidence of effectiveness (experimental); the most annoying are denials that appear to have been made simply to delay payment while appeals are made.

One of the good things in this legislation is that there is a lot of data reporting required of plans in the exchange and also for Medicare. But the big bonus is that if there are national, federal standards, we might finally get some consistency in data reporting, something which most other countries have but we have not had. Data reporting standards are one of the underestimated positives of this legislation.

Posted by: LindaB1 | December 20, 2009 1:36 PM | Report abuse

In denial about the data? Yesterday:

"Shocker: Medicare Has A Higher Claim Denial Rate Than Private Sector Employers"

Posted by: msoja | December 21, 2009 9:53 AM | Report abuse

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