Analysis: Can Nursing Reduce Insurance Claim Denials?
Nursing Colleges Search
When you click on a sponsoring school or program, or fill out a form to request information from a sponsoring school, we may earn a commission. View our advertising disclosure for more details.
The targeted killing of UnitedHealthcare’s CEO Brian Thompson in December 2024 suddenly focused the nation’s attention on health insurance claim denials and their role in the public’s mounting frustration with the industry. Stories shared online recounted how these companies had upended Americans’ lives by denying them coverage.
Dr. Miranda Yaver, a University of Pittsburgh health policy and management professor, told CNBC that “in the aftermath of the killing of the CEO of UnitedHealthcare, we’ve seen a nationwide conversation about health insurance barriers—from delays to denials to just general patient frustrations by everyday Americans from across the political spectrum.”
Widespread headlines and reports indicate that these denials keep rising. Yet nobody knows for sure what these denial rates look like on an ongoing basis, because few federal or state laws and regulations require insurance companies to disclose this data. Nevertheless, some authoritative estimates of these rates have appeared.
“It can be difficult to estimate exactly how many claims are denied in a given year by health insurers because not all health insurers report this data,” Yaver said. “But there are a few things we do know, The Affordable Care Act did a few things to try to help make more transparent this really complex insurance process of coverage denials.”
Interpreting limited data required by the ACA, the health policy nonprofit KFF—the rebranded Kaiser Family Foundation—concluded in a January 2025 study that in 2023, 73 million out of 392 million in-network claims were denied across the nation, or about 19 percent. That’s up from a denial rate of 48 million out of 291 million two years earlier, about a 12 percent increase.
In the KFF study, only 1 percent of those denials was ever appealed, mostly because patients “simply don’t know that they have an appeal right,” according to KFF’s Kaye Pestaina, a vice president of their patient and consumer protection program. The companies only reversed about 44 percent of the claims when patients appealed.
The ValuePenguin Study
However, KFF’s denial rates displayed a huge variance by insurance company and state, ranging between one percent and 54 percent. What’s particularly disturbing are the dramatic disparities in the differential rates of claim denials among the country’s largest health insurance companies.
For example, a study commissioned by ValuePenguin—a consumer advice website owned by the Charlotte, North Carolina online lending marketplace LendingTree—found a 25 percent difference in the care denial rates between the best and the worst companies among the 11 largest health insurance companies in the country.
Claim Denial Percentages for Major Insurance Companies (ValuePenguin)
An updated version of this report now appears prefaced by a series of curious disclaimers. One disclaimer says that an insurer contacted ValuePenguin on December 5, 2024—the day after the Thompson killing—with a claim that the denial rate listed in this article was inconsistent with their internal records. ValuePenguin’s rejoinder refers readers to the survey’s methodology section for information about how the data had been collected, compiled and analyzed, and says that the company will update the article after additional information is made available to its personnel.
Here’s the second disclaimer:
Dec. 6, 2024 — Due to recent events, ValuePenguin removed certain data elements from this piece at the request of law enforcement. If you would like more information about the analysis presented in this piece, please contact [email protected].
Summarized in the chart above, the revised report reveals the best and worst health insurance companies for paying claims. The best is the Oakland, California-based health maintenance organization Kaiser Permanente, which denied only six percent of medical bills.
By far, the worst insurance company for paying claims was Minneapolis-based UnitedHealthcare, the insurance division of UnitedHealth Group, which we’ve covered in several articles on our partner platform MHAOnline.com. This insurance carrier denied one-third of all claims—and UnitedHealthcare was also the company that Thompson managed.
To put that data in perspective, that total was about 27 percent greater than the company with the next highest denial rate, Molina Healthcare, with 26 percent. And UnitedHealthcare’s 33 percent total amounts to a 450 percent increase over the six percent rate of denials by Kaiser.
The U.S. Senate Study
LendingTree’s denial estimate is roughly consistent with another very high estimate released by a United States Senate committee. Examining the records of Medicare beneficiaries over age 65, the panel concluded that UnitedHealthcare’s 2022 denial rate was 23 percent—nine times higher than its denial rate before the pandemic four years earlier in 2019.
The Senate panel also found that UnitedHealthcare also denied prior authorizations for post-acute care—such as care following surgery—at much higher rates than other kinds of care. In particular, those targeted denials resulted in diminished access to this level of care among Medicare Advantage beneficiaries over age 65.
The senators also cited an alarming Stat News investigation along with other media accounts. Here’s what the Senate panel says those publications reported:
NaviHealth, a company owned by UnitedHealthcare’s parent company UnitedHealth Group that contracted with multiple Medicare Advantage insurers, was using artificial intelligence technologies to fix lengths of stay for patients at various inpatient facilities, and in some cases to determine whether those patients should be admitted at all.
As we’ve reported in several of our partner site articles, many companies continue to resist using artificial intelligence platforms where safety could be at risk. That’s because of their tendency to “hallucinate,” in which they report nonsensical results with unwavering conviction—a technical problem that’s not yet solved.
In particular, see our OnlineEducation.com article titled Is Education the AI Industry’s First Killer Application? In that piece, we refer to Babson College management professor Peter Cohan, who reports that most of the $150 billion in artificial intelligence investments during 2024 has not been deployed because companies are “terrified of getting sued” over increasing reports of AI hallucinations and errors. One well-known court decision held Air Canada liable for damages in February 2024 after its customer service chatbot cut a deal to refund a passenger’s ticket for a flight he never took; when the airline discovered the error and refused to pay, the passenger who relied on the chatbot’s assurances sued and won.
In the case of UnitedHealthcare, the estates of two individuals who the company denied care filed a lawsuit against the insurer that’s currently in progress, alleging its use of a flawed AI algorithm denied them coverage that was the proximate cause of their deaths. The plaintiffs are seeking class action certification from a Minnesota federal district court, and their 24-count complaint primarily alleges breach of contract, unjust enrichment and insurance bad faith.
Role of Nursing in Preventing Insurance Denials
The research suggests that such high rates of care denials by insurance companies are often challenging experiences for the clinicians who are involved in the direct care of these patients—especially when the denials could force premature discharges of acute cases, as with the Medicare Advantage patients cited by the Senate panel. Several studies cite care denials as factors that are correlated with severe job-related stress and high rates of burnout among these clinicians, especially those who work in hospital settings.
Given that nurses are among the clinicians who face high rates of exposure to these types of stress, it’s reasonable to ask what role nursing could play in avoiding or preventing insurance denials. It turns out that the research shows there are many steps that nurses can take to reduce the probability that their patients will experience an insurance company’s denial of care.
One expert who’s written extensively on nursing’s role in reducing denials is Dr. Nicolas Abella. He holds a doctorate in nursing practice from Drexel University and before founding the Healthcare Nurses Network, he served for fourteen years as the director of infection prevention and control for Nashville-based Community Health Systems, a 69-hospital chain.
In his November 2024 article “Understanding Denials Management and Nursingʼs Role in Reducing Denials,” Dr. Abella argues that the management of denials can no longer be viewed solely as the responsibility of administrative and billing teams. He advocates that nurses should play critical roles in preventing denials through meticulous treatment documentation.
In the LendingTree study, inaccurate billing codes and patient documentation were the third and fifth most frequent reasons for care denials—both above 33 percent of all rejected claims. Dr. Abella says that nurses can mitigate the risk that patient records omit crucial treatment justifications or responses by meticulously documenting all assessments, interventions, and outcomes.
He provides an example where a simple entry in the electronic health record, such as “patient presented with signs of infection that included elevated temperature and increased white cell counts,” can adequately document the clinical need for intravenous antibiotics. Similar concise documentation techniques appear in this article from American Nurse.
Because coding teams often rely on this kind of nursing documentation to accurately assign diagnosis and procedure codes, Dr. Abella says that another way to prevent claim denials is simply to explain any documentation a third party might consider vague or incomplete. Busy nurses in a hurry might jot down general phrases like “wound care provided” when the best practice would instead be to add in a more detailed and precise account of the care, such as “wound debridement performed with sterile technique per doctor orders.” That is to say, only a few more carefully selected words requiring a few more seconds in the patient’s EHR can make all the difference between an accepted and a rejected claim.
LendingTree also points out that claims denied for lack of medical necessity might simply need additional documentation to demonstrate that the patient needed the treatment—and Dr. Abella concurs that this is frequently the issue with claims to treat straightforward conditions like shortness of breath. All that nurses need to do in these cases, he says, is simply document the clinical justifications for the procedures and treatments. For example, notes that support medical necessity might say “patient exhibited oxygen saturation levels below 90 percent, requiring supplemental oxygen, per doctor’s orders.”
California Nurses Applaud Legislation to Expose and Fine Insurance Denials
Two new bills in the California legislature seek to expose and penalize insurers who repeatedly deny claims. Assembly Bill 682 would mandate public reporting of insurance denials in California, and the similar Senate Bill 363 would fine insurance companies up to $1 million per instance if more than 50 percent of appeals filed with regulators overturn denials during one year.
AB 682 would mandate the public reporting of insurance denials for every plan regulated by two state agencies in Sacramento, the California Department of Insurance and the California Department of Managed Care. The bill would require disclosures of the numbers and costs of claims denied, the reasons for the denials, the outcomes—and whether an artificial intelligence system was used for each decision.
For about 13 million Californians with private insurance, SB 363 would require similar disclosures. But it would also impose staggering penalties on insurers whose denials are overturned by independent medical reviewers more than half of the time. The first reversal would cost the insurer $50,000, the second up to $400,000, and each subsequent reversal would cost the company $1 million each.
Michelle Gutierrez Vo, RN, the president of the California Nurses Association, said in a statement about AB 682 that:
Insurance companies see our patients as numbers on a spreadsheet, but they’re real people to us as nurses at their bedsides. Having publicly available information on why insurers deny claims is a major move to expose how health care is systematically denied to our patients. Nursing is about building trust with our patients; this bill will reveal how that trust is often broken by our healthcare system.
Douglas Mark
WriterWhile a partner in a San Francisco marketing and design firm, for over 20 years Douglas Mark wrote online and print content for the world’s biggest brands, including United Airlines, Union Bank, Ziff Davis, Sebastiani and AT&T. Since his first magazine article appeared in MacUser in 1995, he’s also written on finance and graduate business education in addition to mobile online devices, apps, and technology. Doug graduated in the top one percent of his class with a business administration degree from the University of Illinois and studied computer science at Stanford University.