Insurance Claims Management Statistics

Insurance Claims Management Statistics 2023: Facts about Insurance Claims Management outlines the context of what’s happening in the tech world.

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Top Insurance Claims Management Statistics 2023

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Insurance Claims Management “Latest” Statistics

• Every 12 months of evaluations, VBA’s quality assurance method should provide accurate estimates with a 5% margin of error and a 95% confidence level.^[1]
• The median pay is the wage estimate at the 50th percentile, meaning that 50% of employees earn less than the median and 50% of workers earn more than the median.^[2]
• With 95,184 claims, Bay County had the most claims recorded, making up over 60% of all claims made because of Hurricane Michael.^[3]
• In reality, obtaining the information needed to do their task takes knowledge workers 30% of their time.^[4]
• A 2020 Triple-I Consumer survey found that a record high 27% of homeowners claimed they had flood insurance, which is higher than NFIP forecasts.^[5]
• For procedures that required no prior permission or referral, around 10% of rejections were made. 16% were for prohibited services. 2% were because of medical necessity, and 72% were for other reasons.^[6]
• And a 2018 investigation by the HHS Inspector General found that medicare advantage plans, which are also governed by CMS, typically rejected 8% of claims.^[6]
• In contrast, a survey by FAIR Health on mental health trends in private insurance found that behavioral health diagnoses made up 2.7% of all medical claim lines in 2017.^[6]
• In contrast, HealthCare.gov insurers reported an average in-network claims rejection rate for their individual market plans of 14% in 2018, 17.4% in 2019, and 18.3% in 2020.^[6]
• Three issuers with the greatest market shares in Florida, where the average rejection rate in 2020 was 15%, reported denial rates of 10.5% for Florida BCBS, 11.1% for Health Options, and 27.9% for Celtic Insurance.^[6]
• Although 2% of all claims refused by HealthCare.gov plans were declined because of medical necessity, certain plans with huge numbers of denied claims—75,000 or more—reported considerably higher proportions.^[6]
• 20% of the estimated 765,000 medical necessity rejections for treatments in 2020 were for mental health care.^[6]
• Consumers using HealthCare.gov in 2020 challenged little over 1% of in-network rejections, and 63% of those appeals were upheld by insurers.^[6]
• Less than 10% of 144 reported issuers, or 28 of them, had denial rates. Between 10% and 19% of in-network claims were rejected by 52 issuers. 28 issuers declined over 30% of in-network claims, while 36 issuers denied over 20-30%.^[6]
• Less than 1% to over 80% were among the broad ranges of insurer rejection rates.^[6]
• Fewer than 4% of claims filed to commercial insurers, most of which were claims to big group health plans, were denied.^[6]
• 72% of plan-reported rejections were categorized as having no particular cause and all other reasons.^[6]
• About 16% of claims that were rejected for reasons other than being out of network were rejected because the claim was for an excluded service. 10% because there was no pre-authorization or referral, and just 2% because it was necessary for medical reasons.^[6]
• Nearly one in five HealthCare.gov insurers indicate that they have rejected over 30% of in-network claims, with the average being over 18%.^[6]
• Bronze QHPs will typically deny 15.9% of in-network claims in 2020, compared to 16.2% for gold, 18.9% for silver, 11.8% for platinum, and 18.3% for catastrophic plans.^[6]
• The combined individual and small group market’s average claims rejection rate for in-network and out-of-network claims in 2018, 2019 and 2020 was 16.9%, 14.5%, and 15.3%, respectively.^[6]
• Among HealthCare.gov insurers with comprehensive data, 20% of in-network claims were refused, or roughly 18% of the total.^[6]
• The average healthcare expense per person grew globally between 2007 and 2017 at a compound annual growth rate of over 4%.^[7]
• Certain payers may reduce medical expenses by as much as 10% to 20% by using a digital solution, such as advanced analytics, to prioritize invoices for auditing or identify patients who are likely to submit high-cost claims in the future.^[7]
• After removing contracts with unfulfilled obligations, the entire range of utilization rose to 78%-83%.^[8]
• About 10% of all enrollments each year were under contracts with less than 10 participants, and these contracts were deemed full regardless of use.^[8]
• Approximately 6% of an insurance provider’s outpatient claims for batched visits made up 3% of all claims.^[8]
• The yearly usage rates, according to a preliminary estimate, varied from 67.3% in 1997 to 71% in 2002.^[8]
• With the permissible amounts technique, very few claims were missed in 2002. 96% of all outpatient traditional provider visits were permitted.^[8]
• A contract was only deemed incomplete if usage was lower than 50% and there were at least 10 enrollees.^[8]
• From 1.6% of claims for traditional providers to 26% of claims for CAM providers, this was the case.^[8]
• 50% use of contracts with at least 10 enrollees is required to create a plan to harmonize variable categorization coding demographic information.^[8]
• Conventional physicians earned 63% of the mean billed to the authorized amount for five typical operations.^[8]
• A 1% reduction in the loss ratio for a $1 billion insurer would increase profits by more than $7 million.^[9]

Also Read

How Useful is Insurance Claims Management

One of the key benefits of insurance claims management is the convenience it offers policyholders. When an unforeseen event occurs, such as a car accident or a natural disaster, the last thing anyone wants to deal with is the lengthy and complicated claims process. Insurance claims management streamlines this process by handling all the paperwork, communication with relevant parties, and negotiations on behalf of the policyholder. This ensures that policyholders can focus on getting their lives back on track without the added stress of dealing with insurance companies directly.

Furthermore, insurance claims management helps insurance companies mitigate fraud and reduce the likelihood of paying fraudulent claims. By thoroughly investigating each claim and verifying the details provided by policyholders, insurance claims managers can identify red flags and potential fraudulent activity. This not only protects insurance companies from financial losses but also helps keep insurance premiums affordable for all policyholders. In the long run, preventing fraudulent claims through effective claims management benefits everyone involved in the insurance process.

In addition to fraud prevention, insurance claims management plays a vital role in protecting policyholders from unfair claim denials or underpayments. Without proper claims management, insurance companies may deny legitimate claims or offer insufficient settlements, leaving policyholders financially burdened and disillusioned with their insurance coverage. Claims managers work to ensure that policyholders receive fair and timely compensation for their losses, in accordance with the terms of their insurance policy. This builds trust between policyholders and insurance companies and helps maintain the reputation of the insurance industry as a whole.

Moreover, insurance claims management helps insurance companies assess and mitigate risks, ultimately improving their financial stability. By analyzing claims data and identifying trends in claim frequency and severity, insurance companies can adjust their underwriting practices and pricing strategies to better reflect the risks they face. Claims managers play a key role in this process by providing insights into the types of claims being filed, the cost of settling those claims, and the potential impact on the company’s bottom line. This information allows insurance companies to better allocate resources, manage risk effectively, and remain competitive in an ever-evolving market.

Overall, insurance claims management is a valuable and essential component of the insurance industry. It not only benefits policyholders by providing convenience, protecting them from fraud, and ensuring fair compensation but also helps insurance companies improve their operational efficiency, mitigate risks, and maintain financial stability. Without effective claims management, the insurance industry would struggle to fulfill its core purpose of providing financial protection and peace of mind to individuals and businesses.

Reference

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1. va – https://www.benefits.va.gov/reports/detailed_claims_data.asp
2. bls – https://www.bls.gov/oes/current/oes439041.htm
3. floir – https://www.floir.com/Office/HurricaneSeason/HurricaneMichaelClaimsData.aspx
4. ibm – https://www.ibm.com/blogs/watson/?p=10138
5. iii – https://www.iii.org/fact-statistic/facts-statistics-flood-insurance
6. kff – https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/
7. mckinsey – https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/for-better-healthcare-claims-management-think-digital-first
8. nih – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1533763/
9. sas – https://www.sas.com/en_us/insights/articles/risk-fraud/big-data-analytics-improves-claims-processing.html