The Connection Between Patient Demographics and Insurance Denials

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When it comes to cost-sharing—which represents a portion of healthcare costs that a patient is to pay out-of-pocket (OOP)—the Patient Protection and Affordable Care Act (ACA) exempts high-value preventive services from cost-sharing. Despite this legislation, patients oftentimes find themselves paying OOP due to a multitude of factors, such as misunderstandings between medical institution billing staff, insurers, and hospitals.

These types of unexpected cost-sharing impact access to high-value services; in fact, the use of preventive care is hovering below the recommended proportion,^1,2 and has been found to be even lower for marginalized and at-risk patient groups.

Keeping this in mind, a cohort study published in JAMA Network Open³ sought to explore the connection between patient demographics and social determinants of health (SDOH), raising the question, are they in fact associated with denials of insurance claims for preventive care?

The study investigators pulled patient data from the Symphony Health Solutions’ Integrated DataVerse from 2017 to 2020. This included (but was not limited to) demographics and detailed claims for individuals ages 18-65 living in all 50 states and Washington, DC, who were observed for at least 6 months. Multiple insurance payers were also included.

The SDOH data consisted of self-reported information on household income and education, along with race and ethnicity. These data were gathered from voter registration and purchase transactions, and then were linked to claims data. Race and ethnicity data were classified using self-reported data and electronic health record data, which were then bolstered by the data provider with the help of an algorithm that used both patient name and location.

Overall, there were 1,535 ,181 patients that received a total of 4 ,218 ,512 preventive services in 2,507, 943 unique visits (mean [SD] age at visits, 54.02 [13.19] years; there were 1,804,637 visits for female patients [71.96%]); 585,299 patients (23.30%) who had a yearly household income of $100 000 or higher, while 824,540 patients had some form of college education (32.88%).

A total of 20,658 individuals (0.82%) 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 that were not included in the other four groups.

Out of the preventive claims, 1.34% (95% confidence interval, CI, 1.32%-1.36%) were denied, with majority being 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 a 43.0% higher chance of experiencing a denial than the highest-income patients (odds ratio, 1.43; 95% CI, 1.37-1.50; P < .001), while the least educated enrollees had a denial rate of 1.79% (95% CI, 1.76%-1.82%) compared with 1.14% (95% CI, 1.12%-1.16%) for enrollees with college degrees. Denial rates for Asian (2.72%; 95% CI, 2.55%-2.90%), Hispanic (2.44%; 95% CI, 2.38%-2.50%), and non-Hispanic Black (2.04%; 95% CI, 1.99%-2.08%) patients were significantly higher than those for non-Hispanic White patients (1.13%; 95% CI, 1.12%-1.15%).

The study investigators concluded that, “This cohort study examined the association of patient demographics and inappropriate billing for preventive care, including claim denials and cost-sharing. Patients from at-risk groups, including those with low household incomes and little formal education and those from minoritized racial and ethnic backgrounds were more likely to have claims for preventive services denied or incur cost-sharing for these services that should be cost-sharing exempt. This study adds to the policy discussions around promoting equitable access to primary health care, including preventive services. Our findings highlight that greater attention must be paid to patient demographics when promoting policies to ensure free access to preventive care.”

References

1. Nelson HD, Cantor A, Wagner J, et al. Achieving health equity in preventive services: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2020;172(4):258-271. doi:10.7326/M19-3199

2. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-2645. doi:10.1056/NEJMsa022615

3. 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