Tuesday, Feb. 25, 2025
Do states routinely audit insurers for denying health care claims?
Experts said they know of no states that routinely audit insurance companies over denying health care claims.
Wisconsin Gov. Tony Evers said Feb. 18 he wants to make his state the first to audit based on high rates of claim denials and do “corrective action” enforced through fines.
The Wisconsin insurance commissioner’s office and experts from the KFF health policy nonprofit and Georgetown University said they know of no states using claim denial rates to trigger audits.
The National Association of Insurance Commissioners and the national state auditors association said they do not track whether states do such auditing.
ProPublica reported in 2023 it surveyed every state’s insurance agency and found only 45 enforcement actions since 2018 involving denials that violated coverage mandates.
Forty-five percent of U.S. adults surveyed in 2023 said they were billed in the past year for a medical service they thought should have been free or covered by their insurance.
This fact brief is responsive to conversations such as this one.
Sources
- WISN-TV: Wisconsin Gov. Tony Evers is delivering his budget address
- State of Wisconsin: Budget in Brief 2025-27
- Wisconsin Gov. Tony Evers communications director Britt Cudaback: Email, Feb. 19, 2025
- KFF director of Program on Patient and Consumer Protection Kaye Pestaina: Email, Feb. 23, 2025
- JoAnn Volk, founder of Georgetown University's Center on Health Insurance Reforms: Email, Feb. 24, 2025
- National Association of Insurance Commissioners: Email, Feb. 21, 2025
- National Association of State Auditors, Comptrollers and Treasurers: Email, Feb. 20, 2025
- ProPublica: Health Insurers Have Been Breaking State Laws for Years
- The Commonwealth Fund: Unforeseen Health Care Bills and Coverage Denials by Health Insurers in the U.S.
About fact briefs
Fact briefs are bite-sized, well-sourced explanations that offer clear "yes" or "no" answers to questions, confusions, and unsupported claims circulating online. They rely on publicly available data and documents, often from the original source. Fact briefs are written and published by Gigafact contributor publications.
See all fact briefs
Wisconsin Watch, the news arm of the nonpartisan, nonprofit Wisconsin Center for Investigative Journalism, increases the quality and quantity of investigative reporting in Wisconsin, while training current and future investigative journalists. Its work fosters an informed citizenry and strengthens democracy.
Learn MoreLatest Fact Briefs
Does Medicare Advantage cost more than traditional Medicare?
Thursday, May. 8, 2025
Does the federal government recommend more than 70 vaccines for children?
Wednesday, May. 7, 2025