Barragán Challenges UnitedHealth Executive on Denial Rate Claims

Rep. Nanette Barragán confronted UnitedHealth Group executive Stephen Hemsley with sharply different descriptions of how often healthcare is denied.

At a House Energy and Commerce Health Subcommittee hearing, the California Democrat cited a chart showing a 33 percent in-network denial rate for UnitedHealthcare. Hemsley responded that the figure he knew was less than 2 percent. Barragán also said fewer than 1 percent of denied claims are appealed and that insurers reverse 44 percent of appealed denials.

The exchange sounds like a direct factual contradiction. It may also reflect one of the central problems in insurance oversight: the numbers can use different denominators and describe different decisions.

A denial rate needs a precise definition

A calculation may count entire claims or individual claim lines. It may include administrative denials caused by missing information, medical-necessity decisions, out-of-network claims, or services excluded by a contract. It may cover one Marketplace plan, one line of business, or an insurer’s entire national operation.

Prior authorization is another distinct measure. Hemsley discussed a small share of care interactions undergoing prior authorization review and said nearly all care is covered. That does not necessarily answer a statistic about the initial disposition of submitted claims. Both figures could be calculated accurately within their own categories while producing a misleading comparison when placed side by side.

The appeal figures require the same caution. A broad industry or Marketplace estimate should not automatically be treated as a company-specific rate. A reversal can also result from new records or corrected billing, though a high reversal rate still raises questions about whether patients can navigate the process and whether the original decision was sound.

Congress needs comparable reporting

Patients should not need to decode incompatible industry terms to understand whether coverage is working. A useful federal reporting standard would identify the plan type, time period, denominator, initial denial reason, final resolution, appeal rate, and time required to decide the appeal. Medical and administrative denials should be shown separately.

That would let lawmakers compare insurers on equal terms and identify plans where errors or access barriers are concentrated. It would also protect companies from being judged by a statistic drawn from a different product than the one under discussion.

Barragán’s questioning revealed more than a disagreement over one percentage. Without standardized definitions, dramatic figures can generate attention while leaving patients and policymakers unsure what actually happened. Transparent, comparable data are necessary before either a 33 percent claim or a less-than-2-percent response can be evaluated responsibly.