Emergency rooms are the last functioning front doors to American healthcare. As an emergency medicine physician in one of America’s largest cities, I see firsthand how insurance denials stall diagnoses, inflict needless suffering, and drive up costs by pushing routine care into the most expensive setting: the emergency department.
Patients come because we can compress weeks of outpatient work into hours, without the opening battle over insurance prior authorizations. In an emergency, when seconds count, we treat patients immediately. Increasingly, though, our ERs have become America’s default outpatient clinics, caring not only for the critically ill and injured, but for patients with pressing, non-life-threatening conditions whose insurers have blocked access elsewhere.
[time-brightcove not-tgx=”true”]America’s health insurance industry operates on a troubling business model; they save millions of dollars when they reject, or pressure doctors to reject, care. With medical debt among the leading causes of bankruptcy in America, each denied claim can push families closer to financial ruin.
A recent New York Magazine article reports nearly one in five American families are plagued with medical debt. I have seen patients for whom insurers refuse to authorize an MRI — even when testing that reveals a serious surgical condition that, if left untreated, would have left them permanently unable to walk.
Prior authorization is like a permission slip your doctor has to obtain from your health insurer before certain treatments or tests. What was meant to curb unnecessary tests and care has metastasized into a back-and-forth obstacle course of paperwork that can stall necessary treatment, ratcheting up stress and driving up costs.
Internal documents reported by ProPublica show that Cigna doctors denied over 300,000 patients’ care using mass denials, spending an average of 1.2 seconds on each case. Even more alarming, one in four Medicaid requests—the very safety net program for children, the elderly, and those living in poverty—go unanswered. A 2023 study of nearly 20,000 Medicaid enrollees showed that those hit with a procedural denial were 20 percent more likely to visit the ED within 60 days.
Read More: What to Do When Health Insurance Denies Care You Really Need
Some patients have been able to use social media as a spotlight and megaphone to amplify their case, and successfully force the insurance company to reverse their decision. Health policy and management professor Miranda Yaver faced the same roadblocks. After Aetna denied her care, she spent hours on hold, to no avail. Frustrated, she took to Twitter, tagging the company with her story and watched in disbelief as the company not only responded but reversed a $30,000 denial.
We need to keep the heat on insurers, feeding the fire with legislative action that protects patients and stoking it with sustained public pressure. This can’t be a spark that flares and fades; it must spread until the system itself is forced to change.
More than just celebrating the use of social media and relying on hashtags, we need real change. We need clear, patient friendly appeals processes, and real accountability with states and the federal government stepping in when these insurers wrongfully block care.
Insurance companies should provide transparent, real time dashboards for denial rates, and time sensitive appeal portals. Let’s bulldoze the obstacle course the insurance companies constructed and create federal guardrails to protect patients over needless denials. In a system where it takes insurers 1.2 seconds to deny care, every second we waste leaves another patient waiting.
