When insurers deny care, patients pay the price

THE HILL

Mark Cuban, whose new deal with the Trump administration is already lowering prescription drug costs and expanding access for patients, recently asked why health insurers aren’t liable for malpractice when their denials harm patients. As a physician, I have been asking that question for more than 30 years.

The answer is the same now as it was then: No one is holding them accountable. It is time to change that.

Every physician knows the frustration. You examine a patient, review the medical history, apply your training to make a clinical judgement, agree on a treatment plan, and then a denial arrives — not from a treating physician or anyone who has seen the patient, but from an administrator following a checklist, who has no accountability for getting it wrong.

I have lived this. The insurance company physicians who denied care for my patients were often from unrelated specialties, and they always refused my requests for them to examine the patients themselves. Yet when they were pressed to accept medical responsibility for their decisions, the denials were frequently reversed.

I once told an insurer that I hoped the call was being monitored for quality assurance. The next day, his company approved the care plan I had prescribed. Nothing had changed medically. The only thing that changed was that someone felt accountable.

This is not an isolated experience. In the Affordable Care Act marketplace, insurers denied 19 percent of in-network claims in 2024, which ties for the highest rate since the exchanges began. In Medicare Advantage, more than four million prior authorization requests were denied in 2024, and more than 80 percent of appealed denials were overturned. If those denials were medically justified in the first place, why were so many overturned on appeal?

The answer is uncomfortable: Insurers exploit the fact that most patients will never appeal. Doctors do appeal, however, because they know their patients by name.

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