Two out of three denials get reversed. Almost nobody asks.

Wendell here. Fridays are the big system.

At the plant, a rejected work order could go one of two ways, and the difference was never written on the form.

Some died on the foreman's desk. He said no, the paper went in a drawer, and that was the end of it unless somebody chased. Others were wired differently. A rejection went upstairs on its own, to a man who didn't report to the foreman. Same word. Two different meanings, depending on how the circuit was built.

I've been reading how a denial works inside a Medicare Advantage plan. It turns out to be the second kind. Almost nobody seems to know it.

What the numbers say

Insurers now have to publish how often they say no. The first year of that data went up in March. KFF pulled it together three weeks ago, from the six largest Medicare Advantage insurers. About 25 million people.

Twelve percent of standard requests were denied. One in eight. For care a doctor had already decided you needed.

Then the number that made me sit down. Of the denials that were appealed, sixty-seven percent were overturned.

Two-thirds. And denials, KFF says plainly, are rarely appealed at all.

Now the part that explains why that second number is so high, and it's the piece worth carrying.

The circuit

In Medicare Advantage, you appeal. The plan looks again. If it still says no, that is not the end. The case goes automatically to an independent review entity. An outside body. It does not work for your insurer.

Automatically. You don't request it. You don't file anything further. It moves on its own.

That doesn't happen in Medicaid managed care. It doesn't happen in Marketplace plans either.

The federal inspector general looked at both programmes side by side. In 2019, Medicare Advantage plans overturned 82 percent of appealed denials. Medicaid managed care plans overturned 36 percent. Same kind of company, often the same parent company. Different circuit.

The inspector general's reading is that the automatic step does it. A plan that knows an outsider will read the file has reason to read it properly first.

So a denial here isn't a verdict. It's the first reading on a circuit with two more stages wired into it. And the whole thing sits idle unless you throw the switch.

What I'd do with a denial letter

Appeal it. That's the short version, and the arithmetic behind it is two in three.

If the care is urgent, ask for the appeal to be expedited. Last year the median response on an expedited request was under half a day. Not a fortnight. Hours.

And keep the denial letter. It has to state a reason, and that reason is what the next reader examines.

One more, and it's new. Your plan now has to publish its own denial and overturn rates on its website.

Whether you can find them is another matter. KFF said locating the pages was one of the hardest parts of the work. In July the regulator had to spell out that burying a page where ordinary navigation can't reach it doesn't count as published.

Try anyway. The spread is not small. Among the six largest insurers, denials ran from five percent to seventeen. The share overturned on appeal ran from forty percent at one to ninety-three at another.

Same word, different circuit. It was ever thus.

Wendell