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 primary functions of insurance claims management is to process and investigate claims submitted by policyholders. This involves assessing the validity of the claim, determining the extent of coverage provided by the policy, and calculating the amount of compensation to be paid out. By efficiently managing this process, insurance companies can ensure that claims are handled in a timely manner, minimizing delays and reducing the risk of disputes and dissatisfaction among policyholders.

Effective insurance claims management also plays a key role in preventing fraud. Insurance fraud is a significant issue that can impact the profitability of insurance companies and drive up premiums for all policyholders. By carefully reviewing and investigating claims, insurance companies can identify and prevent fraudulent activities, thereby protecting both themselves and their policyholders from potential losses.

Furthermore, insurance claims management can help insurance companies to analyze trends and patterns in claims data, which can be used to identify areas of risk and potential opportunities for improvement. By leveraging this data, insurance companies can improve their underwriting processes, enhance risk assessment, and develop more competitive pricing strategies. This not only benefits insurance companies by reducing losses and improving profitability but also benefits policyholders by enabling insurance companies to offer more competitive rates and better coverage options.

In addition to these benefits, effective insurance claims management can also help to improve the overall customer experience. By providing clear communication, transparent processes, and timely updates on the status of claims, insurance companies can build trust and loyalty among their policyholders. This can lead to higher customer satisfaction, retention, and referrals, ultimately driving growth and profitability for insurance companies.

Overall, insurance claims management is a critical function that plays a vital role in the insurance industry. By efficiently processing and investigating claims, preventing fraud, analyzing data, and improving the customer experience, insurance companies can drive profitability, reduce costs, and enhance their competitive advantage. As such, insurance companies must prioritize and invest in effective claims management practices to maximize the benefits for both themselves and their policyholders. By continuing to improve and innovate in this area, insurance companies can position themselves for long-term success in an increasingly competitive and dynamic market.

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