One in five adults with private insurance coverage said they or a family member was denied a medical service in the past year, even though it was recommended by their doctor.
The Commonwealth Fund released its 2025 Affordability Survey and focus group results on the topic, which found that 8% of coverage denials were due to denied claims, while 13% were due to prior authorization denials. One percent of denied services fell into both categories, according to the report.
The majority (63%) of those who experienced a prior authorization denial said it caused them significant worry or anxiety, while 41% said it caused a delay in care for them or someone in their household. About a third (31%) said the denial ended up costing them more money, and 28% said a health problem got worse as a result of the delay.
Additionally, 8% said a prior authorization denial led them to learn about a serious medical problem later than they would have liked.
Sara Collins, one of the study’s authors and a senior scholar at the Commonwealth Fund, said in a news release that patients often end up caught in the middle of disputes between their providers and their health plans. They are also often unsure how to appeal a decision or what next steps may be available to them.
“We need greater transparency, expanded appeal rights, and standardization of utilization review processes across insurance plans to help patients have confidence in their insurance, which will allow them to stay healthy and avoid medical debt,” Collins said.
Among respondents who had a claim denied, 69% said it cost them or someone in their household more money and 68% said it caused them worry or anxiety. About a third (30%) said a denied claim delayed their medical care and 21% said it made a health problem worse, according to the study.
The study also found that claim denials may be increasing medical debt. Forty-three percent of respondents said a denied claim led them or a member of their household to accumulate medical debt, and 44% said the original amount they were billed was less than $1,000.
Thirty-five percent said the original bill cost was between $1,000 and $5,000, and 15% said their bills were between $5,000 and $10,000. Five percent of respondents said their original bills were more than $10,000.
Just under half (47%) said they appealed a denied claim, and 56% of those who did not appeal said they were not sure if they had the right to do so. Fifty-five percent said they believed an appeal would make a difference and 34% said they were not sure who to contact.
Focus group conversations revealed that for patients who chose to appeal, some said their provider threatened to send their medical bills to collections while they worked to resolve the issue with their insurance company.
