Having insurance was supposed to mean a doctor’s recommendation gets covered. For a growing share of Americans, that is not holding up. A fifth of privately insured working-age adults said they or a family member had doctor-recommended care denied in the past year, according to the Commonwealth Fund’s 2025 Affordability Survey.
This is the conversation I hear most often from the finance and revenue cycle leaders we work with at Revecore. What keeps them up at night is that they can put a name to the patient on the other side of each denial, and they know their team does not have the resources to fight every claim the way they would like to.
Two Ways Patients Feel the Impact
Prior authorization denials and claim denials cost patients in different ways. Among patients whose prior authorization was denied, 41% of those surveyed by the Commonwealth Fund said it delayed their care, and 28% said a health condition got worse while they waited. By contrast, claim denials hit the wallet instead of the calendar: nearly 70% of patients whose claims were denied said it cost their household more money, 43% said it left them with ongoing medical debt, and more than half faced a patient balance of $1,000 or higher.
Not every denied claim becomes the patient’s responsibility. But when patients do face financial exposure, they are often navigating a process they do not understand and may not know how to challenge. Nearly half of patients with a claim denial did not appeal, and among those who didn’t, more than half said they weren’t sure they had the right to. A third couldn’t identify who to call. That confusion can leave patients caught between their provider and insurer, uncertain about what they owe and what happens next.
When Prior Auth Got Easier, Denials Didn’t Go Away —They Moved
Much of this traces back to policy meant to solve the opposite problem. The CMS Interoperability and Prior Authorization rule, finalized in January 2024, and a 2025 industry pledge from AHIP and the Blue Cross Blue Shield Association, pushed payers to loosen front-end authorization requirements. AHIP has since reported an 11% reduction in prior authorizations among participating plans. Easing that front door did not stop insurers from reviewing claims for medical necessity or payer policy. It simply moved that review to the back end, after the service was already rendered. Patient advocates have also flagged denials on care that was previously approved.
What This Is Costing Hospitals
Many of the services now getting denied on the back end are lower-dollar claims, and the staff time to build an appeal often costs more than the claim is worth. This math pushes hospitals toward writing off claims rather than fighting them, even when the denial was wrong. The timing adds pressure: as enhanced ACA premium tax credits lapsed at the end of 2025 and new Medicaid work requirements take effect, millions of additional Americans are expected to become uninsured. Rising denial volumes and a larger uninsured population are landing on hospitals at the same time, compounding the financial impact.
What Health Systems Can Do to Get Ahead
A hospital that fights a denial and wins recovers revenue for itself and keeps a bill that could follow a patient for years from ever reaching them. The health systems handling this best treat denial management as a systemic function rather than a case-by-case scramble: using claims data to flag which denials are winnable before staff spend time on them, appealing low-dollar claims at scale to make the economics work and giving patients plain-language explanations of their appeal rights.
That is the shift hospitals need to make before volume forces their hand. Payers are optimizing for delay, and the hospitals that build the infrastructure to keep pace are the ones whose patients do not end up paying for the gap.
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