How Often Do Health Insurers Deny Doctor-Recommended Care?

One in 5 working-age adults with private health insurance reported that they or a family member were denied coverage for doctor-recommended medical care in the past year, according to a new report from the Commonwealth Fund published June 4.¹

The report, “How Health Insurance Coverage Denials Affect Americans,” draws on the Commonwealth Fund 2025 Affordability Survey of 4589 privately insured adults aged 19 to 64 years, along with 8 online focus groups. Authors Carson Richards; Sara R. Collins, PhD; Avni Gupta, PhD; and Shreya Roy, PhD, all of the Commonwealth Fund, examined 2 types of denials: prior authorization denials and claim denials.² Thirteen percent experienced a prior authorization denial, 8% a claim denial, and 1% both.

In an interview with The American Journal of Managed Care^®, Collins, senior scholar for the expanding coverage and access and tracking health system performance programs at the Commonwealth Fund, said the findings challenge the premise that prior authorization reliably filters out only unnecessary care. "Clearly, prior authorization is hitting both high-value and low-value care," she said. “If patients are telling us that their health problems are worsening, it's an indication that the care that they're waiting for approval on was actually important to their health.”

With 28% of patients reporting worsened health following a denial, she argued the system is not effectively distinguishing between care that is harmful or wasteful and care that is clinically essential.

"It is not clear that the current system is actually only reducing care that might be harmful to patients or low-value care, but actually putting patients in places where they're waiting for care that's been recommended by their doctor in ways that are very stressful,” she said. “That comes through loud and clear in the data.”

Prior Authorization Denials: Delayed Care, Worsening Health

Among those who received a prior authorization denial, 41% said it delayed their medical care, and 28% said their health problem worsened as a result. More than 60% reported the denial caused worry and anxiety, and some focus group participants said the experience led them to avoid seeking care in the future.

Patients frequently described being caught between their providers and insurers with no clear path forward. One man in his early 60s, denied physical therapy after rotator cuff surgery, said, "It's almost like they will always give you an initial denial and see whether or not you'll actually fight them on it."

Claim Denials: Unexpected Bills and Lasting Debt

Claim denials left patients holding bills they didn't anticipate. Nearly 70% of those who experienced one said it cost their household more money, and 43% said it led to medical debt they are still paying off. More than half reported the original denied bill was $1000 or more.

Collins noted that the financial consequences compound the psychological harm, creating a deterrent to future care-seeking. "A lack of trust in the whole process can create a disincentive for people to actually seek health care when they need it," she said. "That can really erode trust, make people fearful of going to get care."

Appeals: Rare, Confusing, and Often Unsuccessful

Only about half of those who experienced a denial chose to appeal, frequently because they didn't know they could. Among those who didn't appeal a prior authorization denial, 43% doubted it would make a difference, 34% weren't sure they had the right, and 32% didn't know who to contact.

Collins said the data reflect a systemic failure of transparency. "I think it really speaks to the complexity of our health care system and the lack of clarity about how people are supposed to use their insurance to get their health care," she said. Patients should know in advance when prior authorization will be required and exactly what to do if a denial comes down—but that information is rarely available.

"For most patients, none of this is clear; it happens, and it's very anxiety-provoking,” she said. “We get 60% to 70% of people telling us how worrisome this was to them or a family member, and there really should be much more clarity about what the process is and what to do when the decisions come down and it's not in your favor.”

Among those who did appeal, prior authorization outcomes were mixed: 30% had the recommended care approved and 25% received an alternative, but one-third of insurers upheld the denial. Claim denial appeals fared worse, with only 33% resulting in a reduced or eliminated bill and more than 60% of patients waiting a month or more for a resolution.

A Patchwork Regulatory Landscape

The authors describe the current rules as fragmented and outdated. Denial standards for employer plans haven't been updated since 2000, and because those plans are governed by the Employee Retirement Income Security Act of 1974 (ERISA), states cannot impose newer consumer protections on them. "Congress would need to reform ERISA," Collins said, calling for consistent standards across all plan types: "We would really want to see that these rules are consistent across public and private insurance... so the processes aren't so variable across insurance plans as they are now."

While major insurers announced voluntary commitments to streamline prior authorization in 2025, Collins said those efforts fall short, explaining, "It's great that they are thinking in terms of voluntary efforts to make this process easier, but it's just not enough." She called on legislators to unify and modernize the regulatory framework: "There's a real need for Congress to step in and try to make sense of all of these different threads of approaches to making this process more transparent, more clear, more fair, and offer much greater guidance to both patients and physicians about how to navigate what has become an enormously complex health insurance system.”

References

1. New survey: one in five privately insured U.S. adults are denied coverage for doctor-recommended care. News release. The Commonwealth Fund. June 4, 2026. Accessed June 4, 2026.
2. Richards C, Collins SR, Gupta A, Roy S. How health insurance coverage denials affect Americans: findings from the Commonwealth Fund 2025 Affordability Survey and Focus Groups. The Commonwealth Fund. Published online June 4, 2026. doi:10.26099/f758-3x19