Medicare Advantage Denies 17 Percent Of Initial Claims; Most Denials Are Reversed, But Provider Payouts Dip 7 Percent

Medicare Advantage Denies 17 Percent Of Initial Claims; Most Denials Are Reversed, But Provider Payouts Dip 7 Percent

This article quantifies the prevalence of claim denials in Medicare Advantage (MA), along with their direct impact on provider revenue. Employing medical claims data from multiple MA plans, covering 30 percent of the entire MA market in 2019, our study found claim denial rates of 17 percent as a share of initial claim submissions. We also found that 57 percent of all claim denials were ultimately overturned. We calculated that denials resulted in a 7 percent net reduction in provider MA revenue, based on the dollar-weighted share of claim denials that were not overturned.

— Health Affairs, June 1, 2025

Vabson, Boris, et al. “Medicare Advantage Denies 17 Percent Of Initial Claims; Most Denials Are Reversed, But Provider Payouts Dip 7 Percent.” Health Affairs, 1 Jun. 2025. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2024.01485.

MA denials cut payouts to providers by 7 percent, study finds

Medicare Advantage denials are eroding healthcare providers’ reimbursement — even when they are successfully appealed and overturned, according to a new study published in Health Affairs. The researchers examined 270 million MA claims for inpatient, noninpatient and physician medical services, and found that health plans initially denied 17.7% of them. Denial rates were highest for noninpatient claims (which included hospital outpatient care and post-acute settings such as home health) at 21.1%.

— McKnight’s Home Care, June 4, 2025

Medicare Advantage Denial Rates Cut Nursing Home Provider Revenue by 7%

While Medicare Advantage claim denials represent 17% of initial claim submissions, including those submitted by nursing home providers, about 57% of these denials are ultimately overturned. However, MA claim denials result in a 7% net reduction in provider MA revenue, due to the dollar-weighted share of claim denials that were not overturned, according to a study published in Health Affairs this month. Findings highlight the financial burden for nursing home operators dealing with denials, even after some payments are recovered.

— Skilled Nursing News, June 3, 2025