At-Risk Patient Populations Face Higher Rates of Claim Denials for Preventive Care

Denials of claims for preventive care were found to be disproportionately higher among at-risk patient populations, including low-income patients, patients with a high school degree or less, and patients from minoritized racial and ethnic groups, according to a new study.¹

Patients seeking free preventive care continue to face cost-sharing and administrative hurdles, a study reveals. | Image credit: REDPIXEL - stock.adobe.com

The cohort study is published in JAMA Network Open.

“The Patient Protection and Affordable Care Act (ACA) eliminated out-of-pocket cost-sharing for recommended preventive care for most privately insured patients,” wrote the researchers of the study. “However, patients seeking preventive care continue to face cost-sharing and administrative hurdles, including claim denials, which may exacerbate inequitable access to care.”

In this study, the researchers aimed to evaluate the impact of patient demographics and social determinants of health (SDOH) on the rate of claim denials for preventive care.

Most health plans cover the cost of preventive services, such as shots and screening tests, and are grouped into 3 categories: preventive services for all adults, for women, and for children.² However, many patients still end up facing out-of-pocket costs for preventive services due to misunderstanding among patients, hospitals, billing staff, and insurers.¹ Yet, little is known about the burden of these claim denials in association with patient demographics and SDOH within the insured population.

The study included a cohort of patients insured through their employers or the Affordable Care Act (ACA) marketplaces. Claims and remittance data was collected from Symphony Health Solutions’ Integrated DataVerse from 2017 to 2020, and the analysis was completed from January to July 2024.

The primary outcome was the frequency of insurer denials for preventive services. Denials were grouped into 5 categories: specific benefit denials, billing errors, coverage lapses, inadequate coverage, and other. Secondary outcomes were charges for denied claims, which approximated patients’ remaining financial responsibility for care.

Additionally, the researchers performed a subgroup analysis across patient household income, education, and race and ethnicity.

The cohort included a total of 1,535,181 patients who received 4,218,512 preventive services in 2,507,943 unique visits. The mean (SD) age at visits was 52.02 (13.19) years.

Of these patients, 23.30% had an annual household income of $100,000 or higher, and 32.88% had some college education. Additionally, 20,658 (0.82%) patients were Asian, 139,950 (5.58%) were Hispanic, 219,646 (8.76%) were non-Hispanic Black, 1,372,223 (54.72%) were non-Hispanic White, and 25,412 (1.01%) were other races and ethnicities.

Of the preventive claims, 1.34% (95% CI, 1.32%-1.36%) were denied, consisting mainly of specific benefit denials (0.67%; 95% CI, 0.66%-0.68%) and billing errors (0.51%; 95% CI, 0.50%-0.52%).

The lowest-income patients had 43.0% higher odds of experiencing a denial compared with the highest-income patients (OR, 1.43; 95% CI, 1.37-1.50; P < .001). Similarly, patients with the lowest education attainment had a higher denial rate of 1.79% (95% CI, 1.76%-1.82%) compared with 1.14% (95% CI, 1.12%-1.16%) for patients with college degrees.

Furthermore, denial rates for minoritized racial and ethnic groups were significantly higher than those for non-Hispanic White patients:

• Asian: 2.72% (95% CI, 2.55%-2.90%)
• Hispanic: 2.44% (95% CI, 2.38%-2.50%)
• Non-Hispanic Black: 2.04% (95% CI, 1.99%-2.08%)
• Non-Hispanic White: 1.13% (95% CI, 1.12%-1.15%)

Therefore, the researchers believe these findings have important policy implications, pointing to the necessity of creating uniform billing standards, resolving differences in billing practices, improving communication and language assistance, and providing heath equity frameworks at all points of contact within the health care system, including for preventive care.

“This study adds to the policy discussions around promoting equitable access to primary health care, including preventive services,” wrote the researchers. “Our findings highlight that greater attention must be paid to patient demographics when promoting policies to ensure free access to preventive care.”

References

1. Hoagland A, Yu O, Horný M. Social determinants of health and insurance claim denials for preventive care. JAMA Netw Open. 2024;7(9):e2433316. doi:10.1001/jamanetworkopen.2024.33316

2. Preventive health services. HealthCare.gov. Accessed September 18, 2024. https://www.healthcare.gov/coverage/preventive-care-benefits/.