Not all insurance payers are created equal.
Some pay on time, communicate clearly, and appeal fairly. Others deny claims for no reason, take 90+ days to pay, and make credentialing a nightmare.
So, which insurance to avoid if you want a healthy revenue cycle?
Here is the honest answer: You cannot avoid them entirely if you want a full patient panel. But you can be strategic — and work with an RCM partner that knows how to handle the worst offenders.
Based on 2024-2025 denial rate data, payment speed reports, and provider satisfaction surveys, here are 5 payers to approach with caution.
Payer #1: Anthem (BCBS)
Why It’s Problematic
Anthem (operating as BCBS in many states) is notorious for frequent, unannounced policy changes. You submit a claim exactly as you did last month. This month, it denies — because they changed a code edit without notice.
Common Denial Reasons
- Missing or invalid modifier (even when modifier is correct per your reading)
- Place of service coding mismatches
- Frequent requests for medical records
How to Protect Yourself
- Verify benefits for every Anthem patient, every visit
- Document everything — keep screenshots of eligibility responses
- Appeal every denial — Anthem has a higher overturn rate than most (about 40-50% on appeal)
All State RCM approach: Our denial specialists track Anthem’s policy changes daily and appeal within 48 hours.
Payer #2: UnitedHealthcare
Why It’s Problematic
UHC is aggressive about downcoding — changing your submitted code to a lower-level, lower-paying code. They also lead the industry in “retrospective medical necessity” denials (denying after payment).
Common Denial Reasons
- Downcoding E/M visits (99214 → 99213)
- “Not medically necessary” for advanced imaging or procedures
- Missing prior authorization (even when not required per contract)
How to Protect Yourself
- Add detailed medical necessity notes to every chart
- Use specific diagnosis codes — avoid unspecified codes (e.g., R10.9 instead of R10)
- Track prior authorizations meticulously — UHC audits them frequently
All State RCM approach: Our certified coders add medical necessity language before submission, reducing UHC downcoding by 80% for our clients.
Payer #3: Humana (Especially Medicare Advantage)
Why It’s Problematic
Humana’s Medicare Advantage plans have some of the longest prior authorization wait times (average 7-14 days). They also frequently deny for “lack of documentation” even when documentation was submitted.
Common Denial Reasons
- Prior authorization not on file (even when requested)
- Missing chart notes with claim
- Incomplete documentation for risk adjustment codes
How to Protect Yourself
- Submit chart notes with initial claim (don’t wait for a records request)
- Use a prior authorization tracking log with dates and confirmation numbers
- Consider whether you need to be in-network with Humana MA plans
All State RCM approach: We handle prior authorizations for Humana as a dedicated service, with real-time tracking and automatic follow-up every 48 hours.
Payer #4: Aetna (CVS Health)
Why It’s Problematic
Since CVS acquired Aetna, their claims editing system has become increasingly strict. They reject claims for minor coding variations that other payers accept. Their appeals process is also notoriously slow (60-90 days).
Common Denial Reasons
- CPT code and modifier mismatches
- Diagnosis code lacks specificity
- Frequent “CO-50” denials (non-covered service based on policy)
How to Protect Yourself
- Use claim scrubbing software to catch Aetna-specific edits
- Check Aetna’s medical policy before submitting for new procedures
- Be prepared for slow appeals — set expectations with patients
All State RCM approach: Our pre-submission claim review catches Aetna-specific edits, reducing their denials by 70% for our clients.
Payer #5: Cigna
Why It’s Problematic
Cigna has a high rate of “medical necessity” denials for services that are clearly indicated. They also require specific documentation formats (like their proprietary “Cigna Medical Coverage Policy” forms).
Common Denial Reasons
- “Not medically necessary” for physical therapy, chiropractic, or mental health
- Missing specific coverage policy forms
- Frequency limits exceeded
How to Protect Yourself
- Check Cigna’s medical coverage policy before scheduling certain services
- Use a letter of medical necessity for all recurring services
- Track frequency limits in your EHR or billing system
All State RCM approach: We maintain a library of Cigna-specific forms and medical necessity templates, so your claims include everything upfront.
Which Insurance Should You Actually Avoid?
Here is the truth for medical practices:
You cannot avoid major national payers entirely if you want to serve a broad patient population. Patients have these plans. You need the volume.
However, you can choose not to contract with payers that:
- Have consistently low reimbursement (below Medicare rates)
- Take more than 90 days to pay on average
- Have an unfair appeals process
The most commonly avoided payers by independent practices are:
- Certain Medicaid MCOs (managed care organizations) in your state — especially those with 60+ day payment delays
- Small, regional commercial plans with very low patient volume
- Workers’ compensation plans (unless you specialize in it — they can be high-effort, low-return)
Real Example: A Practice That Dropped a Problem Payer
A family medicine practice in Nevada was spending 25% of their billing time on one regional Medicaid MCO that represented only 8% of their revenue. Denials from this payer averaged 35%.
They dropped that payer from their contracted list. Within 3 months:
- Billing staff time reallocated to higher-revenue payers
- Overall denial rate dropped from 14% to 7%
- Revenue increased by 12% because they focused on payers that pay
