The Denial Problem — Michael Joseph Kissling
The public assumes "Not Medically Necessary" is the primary driver of insurance denials. The data does not support that assumption. A KFF analysis of CMS Transparency in Coverage public use files for the 2024 plan year documented the actual breakdown of in-network claim denials across HealthCare.gov plans. The results are not what the industry wants discussed.
28,113,490 claims
19,612,209 claims
10,129,111 claims
The assumed #1 reason
When a denial carries no clinical rationale — "Other" or "Administrative" — the appeals process has nothing to challenge. You cannot build a medical appeal against a non-medical reason. The insurer has effectively created a denial that requires a physician to build an administrative and legal case rather than a clinical one. That overhead is designed to outlast the patient. 61% of denials in 2024 were constructed this way.
KFF analysis of CMS Transparency in Coverage Public Use Files. Full denial reason breakdown, appeal rates, insurer-by-insurer data.
The full visualization — what people assume vs. what the 2024 data actually shows. Every figure represents 5% of all denied claims.
Other reason!↑ "Other reason not listed" — 36%, 28,113,490 claims
-It's not just you-
it's millions!
Tonight, no reason listed↑ 61% of all denials carry no clinical explanation
Administrative reason!↑ 25% of denials — 19,612,209 claims
that's how they twist it
Fighting for my life,
they just say no
Locked out in the cold,
frozen in the snow
At the time, no reason why
Millions waiting for justice,
we won't fade, won't hide
We're more than paperwork,
more than code you hide behind
Mercy and justice,
this fight is yours —
This fight is yours and mine!