I'm 72 years old and my health insurance is denying my hip replacement surgery — even with lots of proof that I need it. What can I do now?

How often are claims denied?

It can be difficult to get a comprehensive read on the denial rates of all insurers. But the Kaiser Family Foundation (KFF) reported that among Healthcare.gov insurers with complete, accurate data, nearly 17% of all in-network health insurance claims were denied in 2021. Though this may not sound too high, the explanations for the denials were lacking.

While about 14% of those denied claims were rejected based on the service being excluded from coverage, only 2% were denied based on medical necessity. The majority — 77% — were filed under the "all other reasons" category.

Meanwhile, in a 2023 KFF survey, 18% of insured adults said they had a claim denied within the last year that they thought would be processed. KFF also found that people who use more health services are more likely to have claims denied.

Among patients who had more than 10 provider visits in the last year, 27% had a claim denied by their insurer. But for patients who visited a provider less than three times within a year, the denial rate was only 14%.

Those with Medicare Advantage plans experience their own barriers to proper healthcare. KFF says that 99% of Medicare Advantage enrollees must obtain prior authorization for certain high-cost services to make sure they’re medically necessary. When it comes to denials, insurers either fully or partially denied 3.4 million prior authorization requests, or 7.4% in 2022 — up from 5.8% in 2021.

A 2024 survey by Experian Health found that 73% of healthcare providers feel that claim denials are increasing. However, respondents place much of that blame on missing or inaccurate data and patient info rather than insurer greed.

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What to do if your health insurance claim is denied

There are several reasons why a health insurance claim may be denied. If it happens to you, get an understanding of why it was rejected, which your insurer should provide in writing. Sometimes, it may be an easy fix if you have the right information and can follow up with your provider promptly as necessary.

If your insurer denies your claim because it’s deemed not medically necessary, you'll need to present a case. You can do this on your own or with the help of a patient advocate, which some people have access to through their employer benefits.

Whether you're going solo or not, you must file an appeal following your insurer's appeals process. You may need to have your doctor write a letter of medical necessity documenting why you need the procedure or treatment.

If you can't work things out with your insurer and your appeal is denied, you can try an external review. In this case, a third party assesses your insurance claim and makes a ruling. If the matter is urgent, you can typically request an expedited review.

Things work a little bit differently if you have a Medicare Advantage plan. In that case, the appeals process has five levels.

The first is a reconsideration of your plan, which is akin to a basic appeal. The second level is an independent third-party review. You can file a Level 3 appeal to the Office of Medicare Hearings and Appeals from there. Beyond that, a Level 4 appeal involves a review by the Medicare Appeals Council. Lastly, a Level 5 appeal involves a judicial review by a federal district court.

You should receive instructions at each stage of the process. So while it may seem daunting, it's best to take it one step at a time.