IBX's Keystone Health Plan East had Pa.'s highest insurance claim denial rate last year

Oct. 24—IBX's Keystone Health Plan East continued to have Pennsylvania's highest claim denial rate last year among plans sold on the Obamacare marketplace, the Pennsylvania Insurance Department reported this month.

The health plan denied 20.6% of 4.5 million claims. Insurance department data show that 2023 was the fourth year in a row that Keystone Health Plan East had the highest rate of denials for plans sold on Pennie, the state's marketplace for insurance sold under the Affordable Care Act.

Pennsylvania's overall denial rate was 13.8%, compared to a national rate of 18.1% for plans sold on the health insurance exchange operated by the federal government, the insurance department said. Its Transparency in Coverage report reviewed data on both medical and pharmacy claims.

Independence Blue Cross cited many possible reasons for denials in an e-mailed statement. Many claims are denied for administrative reasons, such as a service not being covered under the plan, or the patient having already used the allowed number of services. Some individual claims are denied because the services already were covered by a single payment for a collection of services, IBX said.

Sometimes the plan denies pharmacy claims because it's too soon for a refill, or a medication wouldn't be safe because of an interaction with another drug, IBX said.

"We are committed to making sure our members get the right care, at the right time, in the right setting, and consistent with evidence-based guidelines and national standards of medicine," IBX said. "And we are doing things to reduce the burden of precertification on providers and our members through technology advances that ultimately will also reduce denials."

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