Doctor's orders aren't enough: Insurance denials leave millions delayed, sicker and in debt

More than 20% of Americans with private health insurance had their treatments delayed or denied due to prior authorizations and claim denials last year, according to a new report from The Commonwealth Fund.

The findings reveal a widespread problem with serious consequences for patients' health and finances, according to the researchers.

"The complexity of the U.S. health care system is leaving many patients and their families caught between their providers and their insurance companies,” co-author Sara R. Collins said in a news release announcing the report. Collins is Commonwealth Fund Senior Scholar for Expanding Coverage and Access and Tracking Health System Performance.

“When an insurer denies coverage for care their doctor recommends, patients are frequently unsure of how to appeal decisions or even if they have a right to appeal,” Collins said. “We need greater transparency, expansion of appeal rights, and standardization of utilization review processes across all insurance plans to help patients have confidence in their insurance — that it will enable them to stay healthy and avoid medical debt.”

Two types of denials

The survey examined two categories of coverage denials. Prior authorization denials occurred before care is received and require patients or their physicians to obtain insurer approval in advance. Claim denials occurred after care has already been provided, leaving patients unexpectedly responsible for bills they believed would be covered.

A full 13% of privately insured adults reported a prior authorization denial in the past year, while 8% experienced a claim denial and 1% faced both types. Together, 21% reported at least one denial affecting themselves or a family member.

Delays, worsening health and anxiety

For patients awaiting prior authorization decisions, the consequences were often immediate and harmful. Among those who experienced a prior authorization denial, 41% said it delayed their care. A full 28% said their health problem worsened as a result of that delay. More than 60% said the denial caused them worry and anxiety.

In eight online focus groups conducted alongside the survey, participants described the psychological toll of denials in stark terms. Some said the experience had led them to avoid seeking medical care afterward — a finding the report's authors describe as particularly troubling for long-term health outcomes.

Debt and financial hardship

Claim denials — those issued after care has already been delivered — carried their own damaging consequences, primarily financial. Nearly 70% of those who received a claim denial said it cost their household more money. Two in five, or 43%, said the denial resulted in medical debt they are still paying off. More than half of those affected said the original denied bill was $1,000 or more.

Few patients appeal — and many don't know they can

Despite the availability of appeals processes, only about half of patients who experienced a denial chose to challenge the decision. Many said they were unsure they had the right to appeal, or doubted it would make a difference.

• Among those who did appeal a prior authorization denial, the outcomes were often favorable: 30% ultimately received coverage for the originally recommended care
• 25% received coverage for an alternative treatment
• 33% of those who challenged a claim denial had their bills reduced or eliminated

Still, the appeals process itself was a source of frustration. Many patients reported waiting two weeks or longer for a decision after filing an appeal.

"When delivering health care, the goal is to get patients what they need, when they need it — and decisions about care should be guided by the clinicians and care teams who understand their patients best,” Commonwealth Fund President Joseph R. Betancourt, M.D., said in a statement.

“As a primary care physician, I've seen firsthand how challenging it is for patients trying to manage the complexity of the prior authorization process. It is difficult, time-consuming, and frustrating for all involved,” Betancourt said. “In many cases, it leads to delayed care or no care at all; in the worst cases, it puts patients' lives at risk. When oversight overrides clinical judgment without good reason, quality of care and patient safety suffer, and that demands a policy response."

Policy recommendations

The report's authors note that the rules governing coverage denials and patients' appeal rights vary widely across health plans and have not kept pace with changes in the insurance market. They outline several policy options to strengthen consumer protections:

• Expanding patients' right to appeal and making all denials eligible for independent, third-party review
• Standardizing prior authorization procedures across health plans
• Restoring federal funding for consumer assistance programs that help patients understand their coverage and navigate the appeals process.
• Expanding public reporting requirements on claim denials and appeals to improve insurer transparency and accountability
• For insurers, providing clear, plain-language explanations of coverage decisions and appeal rights

Broad impact on a large population

The survey's weighted sample is representative of approximately 130.6 million U.S. adults ages 19 to 64 with private insurance, meaning the 21% denial rate translates to tens of millions of Americans affected each year. The margin of sampling error for the private insurance subgroup is plus or minus 1.7 percentage points at the 95 percent confidence level.

The data comes from the Commonwealth Fund 2025 Affordability Survey, which included responses from 4,589 adults ages 19 to 64 with private insurance, defined as coverage through an employer, the Affordable Care Act marketplaces or the individual market. The survey was conducted by research firm SSRS from July through October 2025 among a nationally representative sample of 6,353 adults.

The findings arrive as federal and state lawmakers face growing pressure to act on prior authorization reform. Several states have passed legislation in recent years requiring faster turnaround times on authorization requests and expanding independent review rights, though advocates say enforcement remains inconsistent and protections vary considerably depending on the type of health plan a patient holds.

Physicians themselves generally have been skeptical about payer platitudes about reforming prior authorizations. Last month, the American Medical Association released data from a 2025 survey that found doctors have little faith that real changes will be fast or effective.