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.