Texas sees among the highest claims denial rates in the country for health plans available through insurers of qualified health plans (QHPs) sold on HealthCare.gov, at 22%, according to a new KFF brief. Nationwide, one in five claims are denied by such plans.
In Texas, individual plans’ in-network denial rate for HealthCare.gov issuers ranged from 12% to 36%. Only five states – Alabama, Alaska, Hawaii, Indiana, and Oklahoma – experienced higher average in-network denial rates.
Five of the six insurers with the highest in-network denial rates in 2023 provide ACA Marketplace plans in Texas. UnitedHealth Group, with the top market share, was shown in the study to have the most denials.
In-network denial rates for insurers operating in Texas, per the study, included:
- Health Care Services Corporation, which includes Blue Cross and Blue Shield of Texas (BCBSTX), 29%;
In 2023, 19% of in-network claims and 37% of out-of-network claims were denied by insurers of qualified health plans sold via HealthCare.gov, the KFF study asserts, with a combined average denial rate of 20% of all claims, a level not reached since 2015, and up from 16% in 2022. With premiums also on the rise in the study’s time frame, the Texas Medical Association notes patients are paying more per month with increased denials of service.
The brief did not provide out-of-network denial rates for individual states.
TMA is taking note of those numbers and encourages physicians with claim denial issues to utilize its Physician Payment Resource Center (PPRC).
In the past two years, TMA’s Physician Payment Resource Center has recovered nearly $7 million in payments from insurers on behalf of physicians, tied to a range of issues including claim denials, credentialing, and prior authorization.
TMA also continues to meet regularly with Texas’ top health insurers to advocate for streamlining best practices to facilitate claim acceptances and timely payment, for instance.
Need insurance-related assistance? Use this form to request payment services from TMA’s PPRC.
Last Updated On
February 11, 2025
Originally Published On
February 11, 2025
Phil West
Associate Editor
(512) 370-1394
phil.west[at]texmed[dot]org
Phil West is a writer and editor whose publications include the Los Angeles Times, Seattle Times, Austin American-Statesman, and San Antonio Express-News. He earned a BA in journalism from the University of Washington and an MFA from the University of Texas at Austin’s James A. Michener Center for Writers. He lives in Austin with his wife, children, and a trio of free-spirited dogs.