Resubmitting them is an aggravating waste of time and money. Even worse, the delays caused by the need to fill out more forms can harm patients, who may need to wait for the treatments they need. <\/p>\n
Around 1 in 5 claims submitted to Massachusetts health insurers in 2024 were denied. But the newly released data show that fewer than 1 percent of those denials were for medical reasons. <\/p>\n
Get The Gavel<\/p>\n
A weekly SCOTUS explainer newsletter by columnist Kimberly Atkins Stohr.<\/p>\n
Some denials were because a service or provider wasn\u2019t covered by the plan, which is at least an understandable reason. <\/p>\n
But most denials \u2014 81 percent, or a total of 7.6 million claims in 2024 \u2014 were for administrative reasons. These could include claims that were duplicates, had a coding error, were incomplete, lacked documentation, or were submitted late. (The data don\u2019t say whether the claim was ultimately paid or not.)<\/p>\n
As Massachusetts struggles to get high health care costs under control, one low-hanging fruit is reducing administrative waste. The new data<\/a> point to insurance claims as a perfect place to look. <\/p>\n If 7.6 million claims were denied in a year because, effectively, someone made a paperwork mistake, that suggests the system is too complicated and mistake-prone. Simplifying it would help providers, insurers, and patients.<\/p>\n Massachusetts Medical Society President Olivia Liao told the editorial board that the data highlight \u201can overly complex system in which carriers impose widely varying coverage requirements, payment rules, and submission protocols.\u201d <\/p>\n It\u2019s a system so complicated that both insurers and providers hire third parties to navigate it: Hospitals pay billing companies, while insurers hire companies to handle claims for particular specialties. <\/p>\n Those companies also need to be paid, of course, adding to the system\u2019s overall cost. <\/p>\n As Health Policy Commissioner Keith Marzilli Ericson, a Boston University economist, noted at a commission meeting<\/a> Thursday, the number of administrative denials is surprising because administrative problems should be solvable. <\/p>\n For example, software could prescreen claims to flag simple problems and catch incomplete claims before they are submitted.<\/p>\n The blame for the snafus that routinely happen now doesn\u2019t fall solely with insurers or providers. Both need to work together, with government and experts, to determine what\u2019s causing administrative denials and how to reduce them.<\/p>\n That includes investigating which insurers and providers have higher rates of denials to see if their processes can be improved. For example, according to the data<\/a>, UnitedHealthcare had the highest percentage of claim denials, 28 percent, followed by Harvard Pilgrim Health Care and Aetna. UnitedHealthcare has been sued<\/a> for using artificial intelligence to automatically deny coverage for care. <\/p>\n One potential solution is standardizing billing, so that different insurers use the same codes to refer to the same things. <\/p>\n For example, the Health Policy Commission wrote<\/a> in a 2025 report that the American Medical Association recommends a set of billing codes that should be used for a screening colonoscopy. But two major Massachusetts insurers have very different requirements \u2014 different from both the association and from each other \u2014 for which codes to use. If insurers could agree on a single set of billing codes for common procedures, that would reduce the opportunity for errors. <\/p>\n Similarly, if insurers could agree on what information is needed for a particular claim, that would reduce the likelihood of providers failing to submit that information. <\/p>\n At the same time, providers need to know how to correctly submit billing. Lora Pellegrini, president of the Massachusetts Association of Health Plans, said insurers often have problems with \u201cbundled\u201d payments, where a set of services are paid together. Providers may then erroneously submit claims for services that were already covered in a previously approved \u201cbundle\u201d payment, which requires the insurer to deny those subsequent claims. Blue Cross Blue Shield of Massachusetts gave the example of a payment for a surgery that also covers 90 days of post-operative follow-up visits. If a physician bills the insurance for an office visit during those 90 days, the insurer would have to deny the claim to avoid double-paying.<\/p>\n Another solution is moving toward full electronic submission of claims and prior authorization requests, so information can be more easily input and reviewed. It\u2019s anachronistic that some communication still occurs via fax. Insurance Commissioner Michael Caljouw suggested at the Health Policy Commission meeting that the health system needs to move entirely away from paper-based claims.<\/p>\n Work in these areas is already ongoing. New rules, under review by the Division of Insurance, will limit<\/a> when insurers can require prior authorization and ensure continuity of care when someone switches insurers. <\/p>\n The Massachusetts Health Data Consortium has already developed a platform<\/a> providers can use to submit claims to multiple insurers, verify patient benefits, or check on claim status. Work is ongoing to use the portal to simplify prior authorization requests. According to the Massachusetts Association of Health Plans, almost all payers and providers use the platform, which makes it a good tool for future standardization and simplification.<\/p>\n There are also more systemic solutions. For example, value-based payment systems, where insurers pay doctors a per-person fee for keeping a population healthy rather than paying for each service, eliminate the need to submit claims for every service. <\/p>\n Removing administrative waste won\u2019t solve the problem of high health care costs. But it\u2019s an easy way to eliminate unnecessary costs while reducing provider workloads and avoiding care delays.<\/p>\n Editorials represent the views of the Boston Globe Editorial Board. Follow us @GlobeOpinion<\/a>.\n<\/p>\n