Are patients giving up on prior authorization denials they could win?

A patient leaves the office with a new prescription and a plan. A few days later the pharmacy calls to say the insurer needs prior authorization. Days pass, then a week. The patient calls the plan, then the practice, then the plan again. Eventually they stop calling and never fill the prescription. The physician may not find out until the next visit, if there is one.

A new national survey suggests this happens far more often than most practices realize. Of respondents who faced a prior authorization delay, denial or medication restriction, 62% said they gave up on care. Across the full sample, 48% said the same.

The survey was commissioned by Penguin Ai, a health care artificial intelligence company that sells software to payers and providers, including prior authorization tools. It covered 500 U.S. adults and was fielded in November 2026. Every respondent had needed at least one prior authorization for themselves or a family member in the past two years. The 62% figure comes from the 273 respondents who reported a delay, denial or medication restriction. The release does not say how respondents were recruited or how the survey was conducted, so the findings are best read as one snapshot of patient experience, not as definitive national data.

Still, the numbers line up closely with what physicians have been telling the American Medical Association (AMA) for years. And they add something physician surveys can't capture: what happens on the patient's side after the request leaves the practice.

Walking away from fights they could win

The survey's most striking finding may be about appeals. Forty-four percent of respondents appealed. Of those, 47% had the decision overturned, 24% saw it upheld, 20% were still waiting and 8% gave up partway through.

In other words, patients who pushed back won about as often as they lost, yet most of the people who hit a barrier never got that far. Penguin Ai co-founder and CEO Fawad Butt summed up the paradox in the release, saying that "Patients are leaving a process that often rules in their favor."

Practices are walking away too. The AMA's 2025 Prior Authorization Physician Survey, which found deep physician skepticism about insurers' prior authorization reform pledge, was reported by Medical Economics in May. It found that 32% of physicians say their prior authorization requests are often or always denied. Asked why they don't appeal, 59% said past experience suggests an appeal won't succeed, 52% cited insufficient staff time and 49% said patient care can't wait.

So both sides of the exam room are giving up on a process that, by at least one measure, rewards persistence. For patients, that usually means going without care. For practices, it means lost revenue, and patients whose conditions are left to progress.

What abandoned care costs

Going without care is only one outcome. Among all respondents, 36% paid out of pocket, 32% delayed care, 21% skipped care entirely, 17% went to an emergency room or urgent care instead and 13% said their health got worse. Only 20% reported none of these outcomes.

Physicians see these effects downstream. In the AMA survey, 26% reported a serious adverse event for a patient, including hospitalization, permanent impairment or death, and 20% said prior authorization led to a patient's hospitalization. Ninety-five percent said prior authorization delays access to necessary care, and 79% reported patients abandoning recommended treatment because of prior authorization challenges.

The AMA data also counter the argument that prior authorization saves money. Eighty-eight percent of physicians said prior authorization increases overall health care use. They cited step therapy leading to ineffective initial treatment (75%), extra office visits (73%), urgent or emergency visits (47%) and hospitalizations (32%). The 17% of patients in the Penguin Ai survey who ended up in an ER or urgent care clinic are a patient's-eye view of that same pattern.

Some physicians put it more bluntly. Orthopedic surgeon Erica Rowe Urquhart, M.D., Ph.D., MBA, a member of the Medical Economics Editorial Advisory Board, wrote in a June excerpt from her book, published as an account of prior authorization outrage and frustration, that "Too many patients are denied the timely care they need," and that patients and clinicians "find themselves on hold for days or weeks, waiting for health insurance corporations to decide."

The wait, and the silence

Waiting is a big part of the patient experience, and it may explain why so many people give up. In the survey, 62% waited four days or longer for a decision and 14% got a same-day answer. The most common wait was four to seven days (29%).

The process also takes a lot of patients' time and causes real stress. Seventy percent spent at least an hour on calls and paperwork, 16% spent more than five hours, and 49% rated their stress at 4 or 5 out of 5.

Much of that frustration comes from not knowing what's happening. Dean Erhardt, president and CEO of D2 Solutions, a consulting and technology company in St. Charles, Mo., told Medical Economics in May that patients often don't know who to call about a pending request. "In many cases, these patients don't even know who to call when they have questions," he said. The survey data cited in that article found 38% of patients received little or no communication while waiting for approval, and 47% said a lack of transparency left them anxious and uncertain.

Erhardt also said the delays themselves are often unnecessary. He said "there's really no reason, other than structural and infrastructure challenges," for a prior authorization to take days. He added that when submissions go wrong, "the vast majority of those errors are really administrative in nature, not clinical in nature."

That matters for practices, because administrative errors are the part they can most directly control.

Patients are wary of AI

The survey also asked patients about artificial intelligence, which insurers increasingly use in prior authorization review. Few patients know when it's involved. Eight percent were told AI or automated software was involved in their decision, 32% suspected it and 32% had no idea.

Patients have strong feelings about it anyway. Sixty-nine percent said they would be more upset if they learned AI had made or recommended a denial, and 54% said they would switch insurers if AI were used to review claims. But the opposition isn't absolute. Thirty-eight percent would support AI that makes approvals faster and more accurate, 49% would support it only with human oversight and 13% said no.

Physicians are uneasy too. Sixty percent of physicians in the AMA survey said they are concerned that insurers' use of AI-assisted decision-making will increase denial rates.

Vendors argue the technology can cut denials by fixing the problem Erhardt described. Brian Covino, M.D., chief medical officer of Cohere Health, told Medical Economics in August that AI should never be the one to deny care. "Artificial intelligence is never used to deny care. That's non-negotiable," he said. He said incomplete submissions drive many denials: "A significant portion of denials in prior authorization is due to a lack of information needed to make the decision." Covino said his company's prompts for missing documentation have produced "decreases of 30% to 40% in missing-information issues."

Butt said AI should assemble clinical evidence for a human reviewer, who can then focus on clinical judgment. He said health plans and providers can keep more patients from giving up by sending reviewers complete clinical information with the first submission.

What it means for practices

Most of the fixes for prior authorization are in the hands of insurers and regulators, but the survey points to a few things practices can do now.

The first is getting submissions right the first time. If most rejections stem from missing or incorrect paperwork rather than clinical disagreement, a complete first submission is the best protection against the delays that push patients to give up.

The second is closing the communication gap. Patients who know a request is pending, how long it usually takes and who to call are less likely to drop out while they wait. Something as simple as a follow-up call at day three or day five could keep a patient in the process.

The third is rethinking whether to appeal. With nearly half of patient appeals in this survey succeeding, a practice's default of not appealing, driven by past experience and short staffing, may be leaving winnable cases on the table. That doesn't mean appealing everything, but it may mean appealing more often for high-stakes treatments, and telling patients they have the right to appeal on their own.

None of that fixes a system that physicians say is broken. But the survey shows that every request left unresolved affects more than practice workload. Behind a large share of them is a patient who stopped trying.