One in five adults with private insurance coverage said that they or a family member had a medical service denied in the past year, even though it was recommended by their physician.
The Commonwealth Fund released its 2025 Affordability Survey and the results of focus groups on the subject, which found that 8% of coverage denials were due to denied claims, while 13% were due to prior authorization denials. One percent of the denied services fell into both categories, per the report.
A majority (63%) of those who experienced a prior authorization denial said that it caused significant worry or anxiety, while 41% said it led to delay in care for them or someone in their household. Close to a third (31%) said that the denial ended up costing more money, and 28% said that a health problem worsened as a result of the delay.
In addition, 8% said a prior authorization denial led them to learn about a serious medical concern later than they would have liked to.
Sara Collins, one of the study's authors and a senior scholar at the Commonwealth Fund, said in a press release that patients often end up caught in the middle of disputes between their providers and health plans. They are also often unsure of how to appeal a decision or what next steps may be available to them.
"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," said Collins.
Among the respondents who had a claim denied, 69% said it cost them or someone in their household more money and 68% said it caused worry or anxiety. About a third (30%) said a denied claim delayed their medical care, and 21% said it worsened a health concern, according to the study.
The study also found that claims denials may be escalating medical debt. Forty-three percent of those surveyed said that a denied claim led them or a member of their household to accumulate medical debt, with 44% saying the original amount they were billed was less than $1,000.
Thirty-five percent said the original cost of the bill was between $1,000 and $5,000, and 15% said their bills were between $5,000 and $10,000. Five percent of those surveyed said their original bills were more than $10,000.
Just under half (47%) said they appealed a denied claim, with 56% who did not appeal saying they were not sure they had the right to. Fifty-five percent said they believed an appeal would make a difference, and 34% said they weren't sure who to contact.
The focus group conversations revealed that for patients who did choose 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.