3 numbers to pull for each payer every quarter
HealthCare.gov insurers' in-network denial rates ran from 3% to 36% in 2024, per KFF. Track your own payers one by one, from your claims and remittances.
Head of Growth and Operations, JotPsych
Your quarterly totals show what came in. They don't show which payer denies most, pays slowest, or pays below your contract.
Claims denied, in full or in part
divided by claims the payer decided
Median days from claim sent
to payment posted
Allowed amount: payment plus your patient's deductible, coinsurance, and copay
divided by your contracted rate, by code
The formulas' inputs come from your claims and remittances, read with the X12 code list. A percent of contract paid under 100%, after you add back Medicare's 2% sequestration cut, means the payer paid below your contract.
- Pull each payer's denial rate. Count the claims the payer denied, in full or in part, and divide by the claims it decided.
- Pull each payer's days to payment. Count the days from the day you sent each claim to the day its payment posted, and use the median, so one slow claim doesn't skew the number. Check your contract for a payment deadline, and ask the payer about each claim past it.
- Pull each payer's percent of contract paid. For your top codes, add the payment and your patient's share: the deductible, coinsurance, and copay. Your remittance lists that share under group code PR (patient responsibility), as reason codes 1, 2, and 3, per the X12 code list. Divide that sum, the allowed amount, by your contracted rate.
- Check two amounts before you compare. Leave out any other PR amount, such as a non-covered service your patient owes. On a Medicare remittance, add back the 2% sequestration cut, reason code 253 under group code CO (contractual obligation), per Noridian, a Medicare contractor.
- Rank your payers on each number. Compare each payer's denial rate with your practice-wide rate, its median days with your contract's payment deadline, and its percent of contract paid with 100%. Start each list with the payer furthest past its target.
- Act on the payer at the top of each list. Fix the step behind a high denial rate, such as a missed eligibility check or a missing authorization. Ask a payer that pays below your contract to reprocess the underpaid claims. Take slow payments to the payer's provider relations team.
KFF's analysis of 2024 transparency data from insurers on HealthCare.gov. A practice-wide denial rate averages your payers together, so it can hide a payer near the high end.
Insurers' reports to the federal government don't name the services they denied, per KFF’s review of insurer data. Your remittances do. Each remittance lists the payment, the patient's share, and every denied service with its reason code, while your claim records give each sent date.
Pull the same three numbers next quarter. You'll see whether each fix worked. Then pick the next payer to fix.
On the Payer expected rates tab, your fee schedule in JotPsych keeps each payer's contracted rate by code.
Book 15 minutes- KFF, “Claims Denials and Appeals in ACA Marketplace Plans in 2024”, March 24, 2026: KFF analysis of 2024 transparency data from insurers on HealthCare.gov.
- X12, Claim Adjustment Reason Codes: group codes PR and CO and claim adjustment reason codes 1 to 3 and 253; read October 2, 2026.
- Noridian, Medicare Administrative Contractor for Jurisdiction E Part B, “Sequestration”, updated June 24, 2025: reason code 253 shows as CO 253 on the remittance, and the 2 percent reduction in Medicare payment continues until further notice; read October 3, 2026.