- Denial Rate: 1%
- # of Members: 88,000
Avera Health Plans is one of the standout insurance providers when it comes to claim denials, with an incredibly low rate of just 1%. The company’s customer-centric approach has earned it a reputation for providing comprehensive coverage with minimal denial issues. Consumers can trust Avera Health Plans to process claims efficiently and with transparency, leading to fewer headaches when seeking coverage for medical services.
In early 2024, Avera hired a new CEO, Jim Dover, who said, "Cost of pharmaceuticals, biosimilars are going up... How do we respond to the varying changes in technology? Those sort of things. So, we need to put together our game plan. We have a current one. It works well, but it’s reaching its tail end. So, it’s time for us to readdress that,” as reported by Dakota News Now.
- Denial Rate: 2%
- # of Members: Over 500,000
PacificSource Health Plans follows closely behind Avera, with a denial rate of 2%. This low denial rate speaks to the insurer’s commitment to minimizing the complexities associated with claims. PacificSource’s efficiency in processing claims contributes to high customer satisfaction and reduced financial stress for policyholders.
After PacificSource was awarded a Top Workplaces USA 2024 title, John "Espi" Espinola, president and CEO, said, "This national recognition truly belongs to our staff. They are what makes PacificSource such a wonderful and satisfying place to work. I’m honored to be a part of such a great team that works so hard every day to take care of our members, and each other."
- Denial Rate: 4%
- # of Members: 375,000
Providence Health Plan has a denial rate of 4%, which is also considered excellent in the insurance industry. With strong customer support and clear claims guidelines, Providence Health Plan works to minimize the occurrence of claim denials, ensuring that most claims are processed and paid promptly.
On their website, Providence explains their denial process: "If Providence denies your claim, the EOB will contain an explanation of the denial. If we need additional time to process your Claim, we will explain the reason in a notice of delay that we will send you within 30 days after receiving your Claim. We will notify you again within 45 days if additional time is needed."
- Denial Rate: 5%
- # of Members: 200,000
Sanford Health Plan’s denial rate of 5% is well below the industry average, making it an attractive option for those seeking reliable health coverage. With a focus on customer satisfaction, Sanford strives to keep the claims process as simple and transparent as possible.
They describe themselves as "uniquely positioned in the upper Midwest" and "a provider-owned health plan that is part of Sanford Health’s integrated system of care. As one of the largest non-profit, rural health systems in the country, we lead the region in affordable, sustainable health coverage in an evolving health care landscape."
- Denial Rate: 6%
- # of Members: 12.5 million
Known for its high-quality care and customer service, Kaiser Permanente boasts the best claim denial rate among major insurers, with only 6% of claims being denied. This low denial rate is indicative of the insurer’s strong focus on providing efficient, accurate, and accessible healthcare coverage to its members.
On their website, Kaiser writes, "Kaiser Permanente is one of the nation’s largest not-for-profit health plans, serving 12.5 million members. At Kaiser Permanente, physicians are responsible for medical decisions. The Permanente Medical Groups, which provide care for Kaiser Permanente members, continuously develop and refine medical practices to help ensure that care is delivered in the most efficient and effective manner possible."
- Denial Rate: 8.4%
- # of Members: 67 million
With a denial rate of just 8.4%, Medicare is one of the most efficient public payers, with relatively few claims being rejected. This program, primarily for seniors and certain disabled individuals, is designed to ensure broad access to healthcare. Compared to both private insurers and Medicaid, Medicare offers one of the lowest denial rates, making it a preferred option for many Americans, especially seniors who are concerned about healthcare affordability and access.
Despite claiming in October 2025 that he will "fight for and protect Social Security and Medicare," Trump seems to be doing the opposite after his inauguration. The White House temporarily freezes all federal grants and loans, and many fear that Elon Musk's access to Social Security payments will bleed into Medicare.
- Denial Rate: 16.7%
- # of Members: 72 million
Medicaid’s denial rates can vary significantly by state and plan type, but the average denial rate across the U.S. hovers at 16.7%. While this is still higher than Medicare’s denial rate, it’s considered relatively low compared to many private insurers. Medicaid provides health coverage for low-income individuals and families, and it is managed differently in each state, which can influence the frequency and reasons for claim denials. Although Medicaid may have its share of denials, it remains a critical lifeline for millions.
The day President Trump ordered a freeze on federal grants and loans, CBS News reported that "state Medicaid programs said they were locked out of the Department of Health and Human Services system used to track and disburse money." Keep an eye on future policies to see if you are still covered.
- Denial Rate: 26%
- # of Members: 3 million
With a denial rate of 26%, Community First Health Plans ranks similarly to Molina Healthcare in terms of claim denials. This insurance provider, which offers services in specific regions, may require extra diligence from policyholders to ensure that their claims are processed successfully. Individuals using these plans should be prepared to navigate potential denials in order to receive their coverage benefits.
Despite their high denial rate, CEO Theresa Scepanski said in early 2024, "After nearly 30 years of providing fellow citizens of South Texas with much-needed health coverage, we are eager to expand our footprint once again and offer our services to this vulnerable and important population."
- Denial Rate: 26%
- # of Members: 5.2 million
Molina Healthcare, known for its Medicaid and Medicare Advantage plans, denies around 26% of in-network claims. The company serves a wide range of low-income individuals and families, and high denial rates can negatively affect those already struggling with healthcare access. Molina’s denial rate highlights the challenges many enrollees face in obtaining approval for medical services.
"Our strategy is clear and simple,” CEO Joseph Zubretsky said during a February 2024 earnings call. “We are in the business of providing access to high-quality healthcare for individuals relying on government assistance."
- Denial Rate: 28%
- # of Members: Over 20,000
Sendero Health Plans has a denial rate of 28%, making it one of the higher-denying insurance providers in the market. This rate may vary depending on the specifics of the claim and the circumstances surrounding it, but it remains an important consideration for potential customers evaluating their options for health coverage.
One Google reviewer awarded Sendero one star, saying the meager review was "too generous." Michael Fallon wrote, "I had a very frustrating experience with Sendero Health. First, they never answer the phone. ... Emails go unanswered, making it impossible to get any assistance. My family had multiple doctor's visits, and none of the offices could verify that our account was active, even with our insurance cards in hand. ...Ultimately, I had to switch back to UnitedHealthcare, even though my premiums increased significantly."
- Denial Rate: 33%
- # of Members: 1.2 million
AvMed, another health insurance provider, shares a similar claim denial rate of around 33%. This denial rate has raised concerns for policyholders who seek transparency and better communication when claims are disputed. Like UHC, AvMed’s high denial rate can result in delays or denials for necessary medical treatments, causing inconvenience for insured individuals who rely on their coverage for essential care.
With only 1.6 stars on Google reviews, it's clear that customers aren't happy. Countless reviewers claim they'd give "zero stars" if it was an option. Yikes! Perhaps CEO Larry Schreiber needs to switch up the game plan.
- Denial Rate: 33%
- # of Members: 29 million
With a claim denial rate of approximately 33%, UnitedHealthcare (UHC) stands out for its substantial number of denied claims. As one of the largest health insurers in the United States, its denial rates can lead to frustrations among policyholders, especially when it comes to in-network claims. Just look at Luigi Mangione!
In December 2024, Mangione was charged with the murder of UnitedHealthcare CEO Brian Thompson. Mangione planned the attack for months, driven by an ideological disdain for the healthcare industry and repeated in-network denials. Mangione's writings revealed his anger towards "parasitic" health insurance companies and corporate greed. The incident sparked discussions about public distrust in the healthcare system and the potential for violence driven by such sentiments.
While Medicaid’s denial rate is higher than Medicare’s, it still performs better than many private insurers. Managed Medicaid plans, typically operated by private companies like UnitedHealthcare, often experience higher denial rates than traditional Medicaid programs.
Essentially, the involvement of private insurers in managed Medicaid, while intended to improve efficiency, can introduce barriers to accessing care, resulting in denial rates that approach or even surpass those seen in purely private insurance markets. For those eligible for Medicaid, it’s essential to understand that coverage denial can be more common, but the program remains a vital resource for low-income individuals and families. Keep an eye out on federal policies that might affect coverage.
Private insurers often have higher claim denial rates than public payers like Medicare and Medicaid due to several key factors. Private insurers, driven by profit, tend to have stricter definitions of "medical necessity" and may require extensive documentation or prior authorizations, leading to more denials. Their administrative costs, including marketing and sales, can also pressure them to deny claims to offset expenses.
Public payers like Medicare and Medicaid, with a public health mission, prioritize broader access to care. Medicare has standardized procedures and defined services, resulting in lower denials. Medicaid, while having higher denials than Medicare, still fares better than many private insurers. However, Medicaid's denial rates vary by state due to differing administration and the use of managed care plans, which often have higher denials.
