A Denial: Insurers’ Greatest Hit is a Broken Record

One of the seminal musical hits of the 1990s – and arguably ever within the rock genre – ends with a powerful refrain delivered by an iconic voice screaming into the microphone with a rising mix of rage and desperation.

A denial, a denial, a denial, a denial, a denial, a denial!

The song is about youthful angst and finding one’s place in a world that seems to lack understanding. The final refrain speaks to something even more compelling: the struggle to have goals and desires recognized and fulfilled. Sure, it’s tough growing up in any era.

But try being a patient with complex care needs in 2025. The themes are all too similar.

Denial.

If you have insurance coverage in North Carolina or anywhere in the United States, you have likely at some point faced a denial in coverage for a medical service or prescription drug or therapy. Granted, that initial pause may have been part of a legitimate inquiry into a specified course of treatment requiring additional conversation. But even if that were true, how often did you feel the reasons were adequately and clearly explained? Do you know the credentials of the person who reviewed your claim? Was it even a person at all? Did you know how to appeal? Did you just give up?

Prior authorization is designed in part to be a check on rising healthcare costs with the consumer in mind. That’s laudable – except the process doesn’t work for the patient in the way that it could. Rather, the rules have mostly been written by the insurers, who may quietly keep their thumbs on the scale. Patients first, right? Fair. But, then why does the house always seem to come out on top in the end?

Let’s look at some numbers. Nearly 80 percent of patients have reported abandoning a recommended treatment because of current prior authorization barriers. Insurers deny approximately 850 million claims per year – and less than one percent of patients decide to go through the appeals process to challenge the initial denial. Either insurers make almost no mistakes or the steps to appeal need some work. What’s more likely? It takes time and resources to appeal – some hospitals employ entire teams of dozens to help work through these claims. Providers spend around 12 hours per week pursuing claims. That amounts to five weeks per year spent on paperwork rather than care.

Opponents of prior authorization reform might point the finger back at the provider community and claim (see what we did there?) that they are the best line of defense to rising health care costs. They may even point to a flawed and misrepresented article from a well-known and agenda-laden financial publication that ranks North Carolina in an unenviable place with respect to healthcare. That’s lazy. It’s a talking point that ignores the complex reality of the costs of care in the United States. The truth is that a lot of stakeholders bear responsibility. It’s time for the insurance community to admit their contribution.

The good news is that there are solutions. They include a bipartisan bill, the CARE FIRST Act, that recently and overwhelmingly passed in the North Carolina House. The House-passed version of the bill is a commonsense approach to prior authorization reform that acknowledges its utility but also prioritizes access to care. Making the prior authorization process more transparent, tailoring more to the patient, and creating a platform where providers recommending treatment and those reviewing claims can have meaningful exchanges is a very positive step. It will save time. It will save administrative headaches. It will save money. It will save lives.

The only way to really heal the system is to come together to have difficult conversations and rededicate our focus to those we serve. Stakeholders are already at the table. We’re waiting on you, insurers.