What concerns me about these findings is the limited information available about the largest categories.
Administrative reasons include duplicate claims, missing information, late submissions, and other processing problems. Those explanations are understandable, but they don't tell us how often such problems could have been prevented or resolved more efficiently.
Even more troubling from a transparency perspective is the category labeled "Other." It accounts for 36% of reported denial reasons, yet the public data don't provide a detailed explanation of what those reasons involve.
Together, administrative and unspecified categories account for 61% of reported denial reasons. That doesn't mean 61% of claims were improperly denied. The figures describe reported reasons rather than unique claims, and a claim can generate more than one reason during processing.
Nevertheless, the lack of detail makes meaningful evaluation difficult. We don't know how frequently a claim is denied more than once, how much additional work corrections require, or how often the same medical service eventually receives payment.
The problem isn't simply that insurers deny claims. It's that the available information doesn't allow us to determine how much of the denial process represents legitimate insurance administration and how much reflects preventable problems.
Who Pays for the Work of Challenging a Denial?
This is where I think the discussion becomes particularly important.
Insurance companies process claims and coverage requests every day. They have established systems, employees, software, and procedures for handling these transactions. Physicians and hospitals also have administrative systems, although their resources vary considerably.
The patient is in a different position. Most people don't regularly deal with medical necessity criteria, appeal deadlines, billing codes, or insurance contract provisions. They generally encounter these issues only when something has gone wrong, often while they're already coping with a medical condition.
And then there's the physician.
A doctor who believes a treatment is appropriate may need to provide additional documentation, answer requests for information, participate in a peer-to-peer review, or write an appeal. Some practices have dedicated employees to manage this work, but those employees must be paid. The additional effort involved in challenging a denial generally doesn't produce a separate insurance payment simply because the practice has had to do more paperwork.
Even when an insurer ultimately reverses a decision, the physician's office may have absorbed substantial administrative costs. The patient may have lost time, experienced anxiety, or waited longer for care.
Who accounts for those costs?
An insurer's records might show that a disputed treatment was eventually approved. But that final outcome doesn't necessarily capture what happened during the delay, including any worsening of the patient's condition or the work required to obtain approval.
This distinction between the final decision and the cost of reaching it deserves far more attention.
Does the System Reward Insurers When People Give Up?
I've wondered whether health insurance operates, at least in some situations, on a principle that could be described as "deny first, then fight it out."
Consider the economic incentives. When an insurer denies a request, it may avoid or postpone payment. If the patient or physician challenges the decision successfully, the insurer may ultimately have to approve the care or pay the claim. But if a legitimate request is never successfully pursued, the insurer may avoid an expense it otherwise would have incurred.
From that perspective, the effort required to challenge a denial matters. A complicated appeals process doesn't affect both parties equally. Insurers participate in these disputes as a routine business activity, while patients may be encountering the process for the first time.
This doesn't prove that insurers deliberately issue unjustified denials to discourage patients. The federal data don't establish that strategy, and many denials result from valid coverage restrictions or correctable billing problems.
But there's a difference between proving deliberate misconduct and recognizing an economic incentive.
If the consequences of an incorrect denial fall mainly on the patient and the healthcare provider, while the insurer faces little additional cost when a decision is eventually reversed, the system may not provide a strong incentive to minimize avoidable denials and delays.
There's another possibility worth considering. A difficult process may discourage people from pursuing even legitimate disputes, not because their arguments lack merit, but because the time and effort required exceed what they can manage.
The low appeal rates don't prove how frequently this happens. But they certainly don't resolve the concern.
Are Appeals Really an Adequate Solution?
We often tell patients that they have the right to appeal insurance decisions. That's important, and those rights should be protected.
But an appeals process is only as useful as a person's ability to navigate it.
A patient may need to identify the exact reason for denial, obtain medical records, request supporting information from the physician, prepare an appeal, and meet deadlines. Depending on the insurance arrangement and the decision involved, independent review may also be available.
Where does someone learn how to do all this? Who helps when the patient doesn't understand the paperwork? Who takes responsibility when the physician's office is overwhelmed with its own administrative workload?
There are assistance programs, including Medicare counseling services and state insurance agencies. Yet patients may still need to determine which organization has jurisdiction and what kind of assistance it provides. Some agencies explain rights or investigate complaints without managing every aspect of an individual appeal.
The existence of an appeals process doesn't necessarily mean that people have equal ability to use it.
Perhaps the better measure isn't simply how many appeals insurers process or reverse, but how accessible the entire review system is to people who need it.
What Would Make the System More Accountable?
One possible approach would be to make insurers responsible for more of the costs created by avoidable errors and unreasonable delays.
That could mean clearer explanations for denials, faster correction of administrative mistakes, independent review when medical judgments are disputed, and better public reporting on how long disputes take to resolve.
Another possibility is recognizing the administrative costs imposed on healthcare providers. If an insurer repeatedly requests unnecessary information or improperly denies services, should it bear some of the expense required to correct those mistakes?
A more ambitious approach would be to provide stronger independent assistance to patients, not simply through advice, but through organizations capable of managing appeals and collecting information about recurring problems.
I've previously explored the possibility of a nonprofit that could assist with appeals and consolidate evidence of repeated denial or delay patterns. Instead of paying for treatments that insurers refuse to cover, such an organization could help patients and physicians challenge decisions while making systemic problems more visible to regulators.
That proposal would require careful legal, financial, and operational examination. It isn't a complete solution, and different types of insurance fall under different laws and regulatory authorities. But it reflects an important principle: If unequal resources contribute to the problem, the solution may require more than asking individual patients to become better at navigating bureaucracy.
At the same time, insurers have legitimate reasons to review claims and treatments. Any reforms should preserve appropriate checks against fraud, unnecessary care, and incorrect billing. The goal isn't to eliminate insurance oversight. It's to make that oversight more transparent, accurate, and accountable.
What Does This Mean for Someone Who Has Never Had a Denial?
For people like me, who have rarely encountered coverage difficulties, this issue can seem remote.
But our experience may reflect the kinds of healthcare services we've needed rather than the full range of protections or restrictions in our insurance plans.
A person can be satisfied with an insurance plan for years and then encounter a very different experience after a serious diagnosis, hospitalization, or need for specialized treatment. That's when provider networks, authorization requirements, rehabilitation coverage, and appeal procedures can suddenly become important.
I don't think everyone needs to become an insurance expert. But I do think it's worth understanding that an initial denial isn't necessarily a final decision, and that different kinds of denials call for different responses.
For readers facing an immediate denial, the practical questions are where to obtain help, how to understand the reason for the decision, and what deadlines apply. Those questions deserve a separate, detailed guide rather than a few general instructions at the end of this discussion.
The Question I Keep Coming Back To
Health insurance is intended to help people obtain medical care while protecting them from potentially overwhelming expenses. Insurers also have legitimate responsibilities to manage costs and apply coverage rules.
But if a system makes it relatively easy to deny a request and places much of the burden of challenging the decision on patients and physicians, we need to examine whether that balance is appropriate.
The available data show substantial numbers of denials, relatively uncommon appeals, and significant reversals in certain categories of appealed decisions. They don't tell us how many initial denials were unjustified or how much money insurers saved through decisions that were never challenged.
Those unanswered questions matter.
We should be asking not only whether an insurance decision was eventually reversed, but also who paid the price of getting it corrected.
If the costs of an incorrect denial are borne primarily by the patient and the healthcare provider, what gives the insurer a sufficient incentive to get the decision right the first time?
Sources and Further Reading
1. KFF: Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024 (January 28, 2026)
Analysis of Medicare Advantage authorization requests, denial rates, appeals, and overturned decisions.
https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/
2. KFF: Claims Denials and Appeals in ACA Marketplace Plans in 2024 (March 24, 2026)
Analysis of claims denials, reported denial reasons, insurer differences, and appeals among HealthCare.gov plans.
https://www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/
3. KFF: About Us
Background on the research organization, its independence, and its lack of affiliation with Kaiser Permanente.
https://www.kff.org/about-us/
