In a recent analysis of health insurance claims data from 2023, three major insurers operating through Connecticut’s Access Health Exchange were found to have significantly higher denial rates compared to the state average. Aetna, ConnectiCare, and Harvard Pilgrim stood out for their elevated rejection rates, particularly for HMO plans. The statewide average for HMO denials was 29%, while these companies exceeded this figure by considerable margins. Despite the high denial rates, few customers pursued appeals, raising concerns about the complexity and accessibility of the appeals process.

Insurers Face Scrutiny Over Elevated Denial Rates

In the golden hues of autumn, Connecticut residents seeking individual health insurance coverage through the Access Health Exchange faced unexpected challenges. According to an examination of 2023 data from the state’s Insurance Department, Aetna, ConnectiCare, and Harvard Pilgrim emerged as the top offenders in denying claims. For HMO plans, Aetna led with a staggering 39.4% denial rate, closely followed by Harvard Pilgrim at 38.8%, and ConnectiCare at 33.6%. These figures far surpassed the statewide average of 29% for HMO plans.

The situation was only slightly better for indemnity plans, where ConnectiCare, under both its own name and ConnectiCare Benefits, recorded a combined denial rate of 29.7% across 4.7 million claims. Aetna came second with a 28.2% denial rate, while Harvard Pilgrim had a 23.3% rate. The statewide average for indemnity plans was 21.5%, indicating a consistent trend of higher-than-average rejections among these insurers.

Despite the high number of denials, very few customers opted to appeal. Aetna reported no appeals from HMO customers in 2023, while ConnectiCare saw just 19 appeals out of 169,457 denials, reversing only six. Harvard Pilgrim had 12 appeals from 8,257 denials, reversing five. In the realm of indemnity plans, ConnectiCare reversed 283 denials, Aetna reversed 10 out of 181,642, and Harvard Pilgrim reversed nine out of 23,605.

Aetna defended its practices by highlighting its high customer satisfaction scores, but the low number of appeals raises questions about the ease of navigating the appeals process. Lisa Freeman, Executive Director of the Connecticut Center for Patient Safety, expressed concern over the difficulty individuals face when trying to challenge denied claims. She emphasized the importance of involving healthcare providers in the appeals process, especially when treatments are deemed medically necessary.

Freeman suggested that patients seek assistance from their doctors or reach out to advocacy groups like hers to navigate the complex healthcare system. “People often give up because they find the process too convoluted,” she explained. “But there is help available, and it’s crucial to use all available resources.”

From a journalist’s perspective, this situation underscores the broader issues within the healthcare system, where patients may feel powerless against large insurance companies. It highlights the need for clearer communication and more accessible support systems to ensure that individuals can effectively advocate for their health needs. The data serves as a wake-up call for both insurers and policymakers to address these systemic challenges and improve the overall patient experience.