Virginia Insurance Denial Report

The worst health insurers in Virginia
by claim denial rate

Virginia averages a 19.7% denial rate — 0.6 points above the national average. About 440,000 claims are denied annually.

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19.7%
Virginia avg denial rate
19.1%
National average
440,000
Annual denials in state
>80%
Appeals overturned when filed

Health insurance denials in Virginia

In Virginia, the average health insurance claim denial rate stands at 19.7%, slightly above the national average of 19.1%. This statistic translates to approximately 440,000 denied claims annually, impacting countless patients who rely on their insurance for necessary medical care. Such a high denial rate underscores the challenges many Virginians face when seeking coverage for their healthcare needs. Understanding this landscape is crucial for patients as they navigate the complexities of health insurance and advocate for their rights.

Worst insurers in Virginia by denial rate

Source: CMS Marketplace Transparency Report 2023. In-network ACA marketplace claims only.

1

Oscar Health

34.6% denial rate

Oscar denies 34.6% of claims — 15.5 points above the national average. Their appeal overturn rate is 58%.

GLP-1 Medications: 46% deniedMental Health: 41% deniedSpecialty Medications: 38% denied
Full Oscar denial report →
2

Cigna Healthcare

33.1% denial rate

Cigna denies 33.1% of claims — 14.0 points above the national average. Their appeal overturn rate is 61%.

GLP-1 Medications: 44% deniedSpecialty Medications: 40% deniedMental Health: 37% denied
Full Cigna denial report →
3

Kaiser Permanente

12.4% denial rate

Kaiser denies 12.4% of claims — 6.7 points below the national average. Their appeal overturn rate is 70%.

GLP-1 Medications: 19% deniedSpecialty Medications: 15% deniedMental Health: 12% denied
Full Kaiser denial report →

Your rights as a Virginia insurance patient

Virginia law empowers patients with specific rights when facing claim denials. Individuals have the right to an internal appeal, allowing them to challenge the insurer's decision directly. Additionally, they can request an external Independent Medical Review if the internal appeal is unsuccessful. The Virginia Bureau of Insurance oversees these processes, ensuring that patients have a fair opportunity to contest denials. Filing a complaint with this regulatory body is free and can serve as a powerful tool to pressure insurers into reconsidering their decisions.

Virginia Bureau of Insurance
https://www.scc.virginia.gov/pages/Bureau-of-Insurance

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How to appeal a denial in Virginia

  1. 1
    Request the denial in writing
    Ask your insurer for the specific clinical criteria and coverage policy they used to deny you. They are legally required to provide it within 30 days.
  2. 2
    File your internal appeal
    Send a written appeal to your insurer within 180 days. Cite your doctor's clinical documentation, relevant medical guidelines, and Virginia insurance law. A well-written appeal citing specific laws wins over 80% of the time.
  3. 3
    Escalate to the state if denied again
    If your internal appeal is denied, file an Independent Medical Review (IMR) with the Virginia Bureau of Insurance. This is free and decided by independent clinicians. Their decision is often binding.
  4. 4
    Use disputes.health to generate your letter
    Our agents generate a clinic-grade appeal letter in under 15 minutes — citing your state's laws, relevant medical guidelines, and your specific situation. We then submit it to your insurer for you.
How to appeal a denial →GLP-1 denial guide →Mental health denial guide →All public resources →

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