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Bills & Money

Insurers Reverse a Third of the Denials People Appeal, and Fewer Than 1 in 100 Denials Are Ever Appealed

Health insurers on HealthCare.gov denied about one in five in-network claims in 2024 — 85 million of them. Almost nobody fought back, and the people who did won a remarkable share of the time. Appealing is free, the deadline is 180 days, and the first move takes one phone call.

MyCare-Universe · reviewed by a practising physician · 5 min read
The odds when your insurer says no: 19 percent of in-network claims denied, under 1 percent of denials appealed, 34 percent of appeals reversed — and the deadlines that govern the fight
The odds when your insurer says no: 19 percent of in-network claims denied, under 1 percent of denials appealed, 34 percent of appeals reversed — and the deadlines that govern the fight

The letter says your claim was denied, and the letter is counting on what you do next: nothing. That is what almost everyone does. In 2024, insurers selling plans on HealthCare.gov denied about 85 million in-network claims — 19 percent of everything submitted — and consumers appealed fewer than 1 in 100 of them. The few who did appeal got the denial reversed about a third of the time, by the insurer itself, without a lawyer, without a court, without anything but a letter and a deadline. In 2023 the reversal rate was 44 percent. Those are odds nobody would walk away from at a casino, and nearly everybody walks away from them here.

Why "no" is so often not the real answer

Here is what the denial statistics quietly reveal. When federal regulators made insurers report the reasons for their denials, only about 5 percent were for "medical necessity" — the insurer's doctors disagreeing with your doctor. About 25 percent were administrative problems, 13 percent were services the plan says it excludes, 9 percent were a missing prior authorization or referral, and a full 36 percent were listed as "other," which is not a medical judgment either.

Read that again from your side of the table: the great majority of denials are not the insurer saying "you did not need this care." They are a wrong billing code, a form that did not arrive, a referral that was not attached, a box left unticked. Paperwork denials die when someone corrects the paperwork — and insurers know most people never will.

One more thing worth knowing: a surprising number of denials are simple coding errors by the clinic or hospital, and those do not even need an appeal. The billing office can correct the code and resubmit the claim. That is why the first phone call below goes to your doctor's office, not the insurer.

What to do, starting today

This applies to most private insurance — through work or the marketplace. Medicare and Medicaid have their own appeal routes with their own deadlines, but the same principle: the first no is the start of a process, not the end of one.

And one honest tip from the physician's side of the desk: your doctor wants that claim paid too — an unpaid claim usually becomes either their unpaid bill or yours. Ask the billing office for help and you will mostly find an ally who fights these letters all day. The system's arithmetic depends on the 99 people who never write back. The appeal exists for the one who does — and a third of the time, that one letter erases the bill.

Sources

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