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Burn The Playbook
82% of Appealed Denials Get Overturned. They Deny Anyway.
A 2024 study calls it "rationing by inconvenience." Insurers deny claims knowing most people will not fight. In Medicare Advantage, the ones who fight win 82% of the time.
WASHINGTON: Health insurers denied 12% to 18% of standard prior authorization requests in 2025, according to a KFF analysis of the first numbers insurers had to disclose under a 2024 CMS transparency rule. ACA marketplace insurers averaged 18%. In Medicare Advantage, UnitedHealthcare denied the most, at 17%.
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Here is the number they do not want you to see: in Medicare Advantage, 81.7% of the denials that patients or doctors appealed were overturned in 2023, per KFF's read of CMS data. Four times out of five, the initial no did not survive a second look. Only 11.7% of denials were appealed at all. The insurers know this. They deny anyway, because they also know most patients will never file.
A 2024 paper in the Journal of Health Politics, Policy and Law has a name for it: "rationing by inconvenience." The insurer denies your claim. You fight the denial. You wait weeks. You fill out forms. You call back. You hold. You fight again. Most people give up. The insurer keeps the money. The system works exactly as designed.
Read the HHS inspector general's audit yourself, the one that found insurers overturning three out of four of their own denials.
Quick break before the Receipts, and this one is about what you watch after fighting with your insurer.
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The Receipts
1. 12 to 18% denied: Insurers denied 12% to 18% of standard prior authorization requests in 2025, the first disclosures under CMS's 2024 interoperability and prior authorization rule. ACA marketplace plans averaged 18%; UnitedHealthcare led Medicare Advantage at 17%. Source: KFF, August 14, 2026, via Fierce Healthcare and Healthcare Dive.
2. 81.7% overturned on appeal: Of nearly 50 million Medicare Advantage prior authorization decisions in 2023, 3.2 million were denied, 11.7% of those were appealed, and 81.7% of the appeals were fully or partly overturned. The government's own inspector general found the same pattern a decade ago: plans overturned 75% of their own denials from 2014 to 2016. In the new 2025 disclosures, two-thirds of appeals won in Medicare Advantage, about half in Medicaid, and 43% in the ACA marketplaces. Source: KFF analysis of CMS data, January 2025, via AHA News; HHS Office of Inspector General, OEI-09-16-00410, September 2018; KFF, August 2026.
3. "Rationing by inconvenience": Miranda Yaver's 2024 paper in the Journal of Health Politics, Policy and Law, published by Duke University Press, describes the strategy: make the process so burdensome that patients give up. The denial is not a medical judgment. It is a bet that you will quit. Source: Yaver, JHPPL 49(4), August 2024, PubMed.
The Dispatch
An insurance company that denies 18% of requests and loses most of the appeals is not making medical decisions. It is making financial ones.
The CMS transparency rule that forced insurers to report these numbers took effect January 1, 2026. The industry lobbied for years to delay it. Now we know why. The data shows that initial denials are overwhelmingly wrong, not by mistake, but by design.
The system is built to exhaust you. Every phone tree, every form, every "your call is important to us" is a bet that you will hang up. And for most people, the bet pays off. Not for the patient. For the shareholder.
Sources
KFF: analysis of insurers' first prior authorization disclosures under the CMS 2024 rule, 12% to 18% denial rates in 2025, appeal outcomes by market, August 2026, via Fierce Healthcare and Healthcare Dive.
KFF, via AHA News: Medicare Advantage prior authorization in 2023: 3.2 million denials, 11.7% appealed, 81.7% of appeals overturned, January 2025. source
HHS Office of Inspector General: OEI-09-16-00410, Medicare Advantage organizations overturned 75% of their own denials on appeal, 2014 to 2016, September 2018. source
Miranda Yaver, Journal of Health Politics, Policy and Law: "Rationing by Inconvenience: How Insurance Denials Induce Administrative Burdens," 49(4), August 2024. source
American Medical Association: 2025 prior authorization physician survey, 1,000 physicians; 40% say requests are often or always denied. source
— Michael Starr Hopkins · Washington, D.C.
Burn Notice
The denial is not a diagnosis. It is a business strategy.
The insurer denies your claim. You miss the treatment. You get sicker. You come back more expensive. They deny you again. The cycle does not end because ending it would cost them money.
Health insurance is not insurance. It is a subscription to a bureaucracy that profits from saying no.
They call it prior authorization. Duke University calls it rationing by inconvenience. The patient calls it the reason they stopped trying.
— MSH
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