Bloomberg 分析称五大健康险公司预授权拒付率高、上诉后约半数被推翻，但数据系今年早些时候依联邦新规已披露

Few patients appeal when insurers decline to pay for their care. Many don’t even know they can. But new data show that when they do, they frequently win — in some plans, nine out of 10 times.

That dynamic means many Americans can’t get the care their doctors have prescribed without first wading through a bureaucratic process known as prior authorization. Insurers use the practice to decide whether they’ll cover a procedure or drug, and to help avert what they deem unnecessary care. But the high rate at which some companies overturn their own decisions raises questions about why they’re denying so many doctors’ orders in the first place.

Five large publicly traded insurers denied more than 10% of standard prior authorization requests in 2025 for most Medicare, Medicaid and Affordable Care Act plans, according to a Bloomberg News analysis of recently released data. Patients won about half the time on appeals, according to information made available. The five companies together insure more than 160 million people across all their businesses, including commercial health plans not reflected in the new data.

Insurers disclosed this data on their prior authorizations earlier this year to comply with a new federal rule. Even with some blind spots, it paints the fullest picture yet of an inconsistent practice that some have called to abolish.

The impact is broadly felt. A third of insured adults called prior authorizations a major burden in a poll this year by health researcher KFF. The practice drew renewed attention in the backlash to insurers that followed the 2024 shooting death of UnitedHealth Group Inc. insurance chief Brian Thompson.

Under pressure from the public and the government, health insurers aim to standardize and automate this gatekeeping process. They defend it as a crucial check against overtreatment that’s estimated to cost as much as $100 billion a year. AHIP, which represents insurers in Washington, said companies are reducing prior authorization requirements and they respond to most requests in less than a day, faster than federal requirements.

Still, denials can be calamitous for patients.

Amy Smith’s health insurance covered chemotherapy for her rare and hard-to-treat bile duct cancer. Experts at UT MD Anderson Cancer Center in Houston thought she might be a candidate for a liver transplant. “It’s the only chance of a cure,” said Smith, 57, a longtime teacher from Kentucky.

Smith’s insurance paid for extensive testing to check if she’d be eligible. She needed to be stable for at least six months, without the tumor spreading beyond the liver. But when doctors finally gave the green light, the insurance company said it wouldn’t cover the transplant itself. “My hopes were up so much, I never in 100 years imagined it would get denied,” Smith said. “I was at their mercy.”

Blue Cross Blue Shield of Texas denied approval multiple times. “We’re done,” her husband Donnie recalled thinking. “There’s nothing else to do.” Smith ultimately got the transplant approved with the help of Claimable, a company that uses AI to help write appeal letters. She got her new liver in May and has been recovering since. BCBS of Texas didn’t address questions about Smith’s case but said it’s committed to expanding access and aims to help members get appropriate care quickly.

Even some insiders concede the industry has been too slow to act. The reforms underway are “a little late,” said Sachin Jain, CEO of Scan Group and Health Plan, a nonprofit Medicare insurer based in California.

The industry is finally admitting “there’s been a lot of harm that’s been introduced through all the friction that we’re now addressing,” he said. “On the other end of the friction is a person who has a potential cancer diagnosis.”

Archelle Georgiou, a former insurance executive, believes much of that administrative burden could be removed — to the benefit of patients and without hurting companies’ bottom lines. She was chief medical officer at UnitedHealthcare in the 1990s, when the insurer abolished prior authorization, only to bring it back a decade later.

She aimed to turn the newly revealed data into a metric that’s easier to interpret that she calls a “Friction Index.” Her gauge gives extra weight to coverage denials that are overturned when patients appeal. “That is the most egregious because the plan overturned its own original decision,” she said, which needlessly delayed care.

Georgiou, now a strategic adviser to healthcare companies, argues that many insurers could dramatically scale back the most burdensome prior authorizations without giving up valid guardrails against inappropriate care. The metrics are “a starting point, not a verdict,” she said, adding that she’s hopeful they light the way for those changes.

Paring back the number of services that require prior authorizations could mean an insurer’s denial rate — the percentage of requests they deny — goes up “because it’s so much more targeted,” she said. The Friction Index aims to give a clearer picture of the overall burden, not just the percentage of denials.

The Data

Regulators aimed to improve transparency with the publicly available data. But it’s often buried on insurers’ websites.

“What we have today kind of misses the mark,” said Michelle Long, senior policy manager at KFF. The data don’t reflect prescription drug denials. The employer health plans that cover most working-age Americans don’t have to report denial rates.

Two large insurers — Elevance Health Inc. and CVS Health Corp.’s Aetna unit — didn’t publish raw numbers of approval requests and denials for some markets, and declined to share them with Bloomberg.

Even so, any data helps shed light on what has long been considered a black box.

Bloomberg News analyzed average denial rates, not weighted by membership, at the level insurers were required to report them, which varies by line of business. Across the five insurers reviewed, the denial rates varied widely.

Centene denied the highest share of standard prior authorizations in Medicare plans by unweighted average, according to Bloomberg’s review of the data from insurer websites and AuthDenied, a private website that’s aggregating the reports. The company also had the highest rate of reversals.

Medicare plans see the bulk of appeals and reversals compared to other markets.

A spokesperson for UnitedHealthcare, the company’s insurance unit, said that comparing denial rates between companies isn’t useful, because insurers cover different types of patients and require prior authorization for different procedures. The company says it’s reducing the volume of needed authorizations by 30% with many requirements lifting in October.

A representative for CVS Health said the company has standardized 88% of prior authorizations and requires approvals for fewer services than its competitors. A Humana spokesperson said the company has removed a third of prior authorization codes for outpatient services and offers decisions in one business day for “complete” electronic requests. It’s also launching a program to waive the requirements for doctors that adhere to guidelines. UnitedHealth already has such a program.

A representative for Elevance didn’t respond to requests for comment on the data. Centene declined to comment.

AHIP, the insurer trade group, said it’s working to increase the share of requests done electronically and standardizing data doctors need to submit, to simplify and automate the process. The group said plans have eliminated prior authorizations on 11% of medical services, resulting in 6.5 million fewer requests. Companies committed to honoring previous authorizations for three months when patients switch insurance plans. AHIP said it’s flawed to assume that services with high approval rates shouldn’t be subject to prior authorization. Denials can reflect when doctors fail to submit the right documentation.

Mixed Progress

Some healthcare providers say they’ve seen progress. At Duly Health and Care, a large Illinois practice, digital links to insurance companies have cut the time it takes to get a decision, according to Chief Revenue Officer Kerri Balbone. The medical group has fewer staff working on the requests as a result.

Balbone said that in her practice, about 60% of the cases overturned on appeal had been denied because of some administrative error, like missing records or confusion about what was required. The remaining cases involved clinical discussions.

Ben Vallier, CEO of The Iowa Clinic, a physician-owned group with more than 250 providers, said he’s not seeing much improvement. The group still employs about 30 people to work on prior authorizations, the same as last year, he said.

“We kind of laugh when we hear they're going to voluntarily do this or that,” he said. “There’s no voluntary process by which an insurance company is going to give up the ability to make more money.”

The Trump administration this year proposed a rule to streamline prior authorization requests for prescription drugs, requiring insurers to handle the process electronically. It would also make them disclose denial rates for prescriptions. Trump health officials have praised insurance companies for pledging to lower barriers to care. Some say voluntary action isn’t enough. The American Economic Liberties Project, an influential group critical of corporate power, has called for banning the practice in its current form. Multiple Democrats in Congress have also called for overhauling or abolishing the practice in Medicare.

Some question whether the system, which was devised to help keep healthcare costs down, ultimately saves money. When the denial and appeals process delay necessary treatment, patients’ conditions can worsen in ways that make them more expensive to treat, said Miranda Yaver, a health policy assistant professor at the University of Pittsburgh who wrote a book on coverage denials.

“If a patient winds up in the ER or the hospital because they can’t get their important medication, then are we really having the cost savings that we’re promised?” she said.