요약
Americans are paying more for health insurance than ever before. Employers are absorbing extraordinary benefit expenses, employees are contributing thousands of dollars toward coverage, and healthcare organizations are investing heavily in clinical care, tech…
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Americans are paying more for health insurance than ever before. Employers are absorbing extraordinary benefit expenses, employees are contributing thousands of dollars toward coverage, and healthcare organizations are investing heavily in clinical care, technology, documentation, and regulatory compliance.
Yet after all that spending, patients and providers are still being told: “Your claim has been denied.”
This is no longer simply an insurance problem. It is an enterprise risk, workforce, patient-safety, revenue-cycle, data-governance, and public-trust problem that demands executive attention.
The cost of coverage continues to climb
In 2025, the average annual premium for employer-sponsored family health coverage reached $26,993—a 6% increase over the previous year. Employees contributed an average of $6,850 toward that coverage. The average deductible for workers enrolled in plans with a general annual deductible reached $1,886 for individual coverage.
Over five years, family premiums increased approximately 26%.
For employers, healthcare benefits are now a significant part of total compensation. For employees, the financial burden extends far beyond the amount deducted from each paycheck. Families must also manage deductibles, copayments, coinsurance, prescription costs, out-of-network exposure, and services that an insurer may ultimately refuse to cover.
The healthcare affordability conversation, therefore, cannot focus exclusively on premiums. We must also ask what people are actually receiving in exchange for those premiums.
KFF 2025 Employer Health Benefits Survey
The denial problem is equally concerning
An analysis of 2024 federal Marketplace data found that insurers participating in HealthCare.gov denied approximately 19% of in-network claims and 37% of out-of-network claims—about 20% of all submitted claims.
Even more concerning is the variation among insurers. In-network denial rates ranged from approximately 3% to 36%.
A denial rate of one in five claims should command the attention of every healthcare executive, employer, policymaker, and consumer advocate. Although some denials involve duplicate claims, missing information, eligibility problems, coding errors, or services excluded under a benefit plan, the administrative and clinical consequences are still significant.
Every denial creates another transaction.
It may require a corrected claim, additional documentation, a physician review, a peer-to-peer discussion, an appeal, a patient telephone call, or a payment arrangement. Each transaction consumes staff time, delays reimbursement, increases administrative expense, and may postpone care.
KFF analysis of 2024 Marketplace claims denials
Prior authorization has become a clinical issue
Prior authorization was intended to ensure that services were medically appropriate and consistent with coverage requirements. In practice, however, it has become a significant source of friction between physicians, patients, healthcare organizations, and insurers.
The American Medical Association’s 2025 physician survey found that 95% of responding physicians reported that prior authorization delays access to necessary care. Seventy-nine percent said prior authorization can at least sometimes cause patients to abandon recommended treatment.
When an administrative process causes a patient to delay or discontinue clinically recommended care, the issue is no longer merely operational. It becomes a patient-safety concern.
AMA 2025 Prior Authorization Physician Survey
Automation without accountability can magnify the problem
Artificial intelligence and automated decision-support tools can improve claims processing, detect missing information, identify coding inconsistencies, and accelerate routine approvals. However, those same technologies can create serious risks when they are used to recommend or support denials without sufficient transparency, clinical context, or human oversight.
A 2024 U.S. Senate Permanent Subcommittee on Investigations report examined prior-authorization practices involving post-acute care in Medicare Advantage. According to the committee’s findings, one major insurer’s prior-authorization denial rate increased from 10.9% in 2020 to 22.7% in 2022 as multiple automation initiatives were implemented.
That does not mean automation alone caused every denial. It does demonstrate why executives must understand how automated recommendations are produced, how clinical exceptions are handled, how frequently decisions are overturned, and whether qualified clinicians have meaningful authority to intervene.
U.S. Senate report on Medicare Advantage denials
AI should help healthcare organizations make better decisions—not make accountability disappear.
The underlying problem is often fragmented information
Many claim and authorization disputes begin long before a claim reaches the insurer.
The patient’s clinical information may be distributed across multiple systems. The diagnosis documented by the physician may not fully align with the order. The authorization number may not be connected to the final claim. A payer may request documentation that already exists but cannot be accessed through the current workflow. A code may be technically correct but unsupported by the clinical narrative available to the reviewer.
This is why interoperability matters.
An interoperable healthcare environment should make it possible to connect:
- Patient eligibility and benefit information
- Clinical orders and medical-necessity documentation
- Diagnoses, procedures, medications, allergies, and results
- Prior-authorization requirements and decisions
- Claims, remittances, denials, corrections, and appeals
- Patient communications and financial-responsibility information
HL7, FHIR, APIs, electronic medical records, payer systems, and AI can support this work—but only when the data is accurate, governed, traceable, and available at the correct point in the workflow.
Technology cannot correct a process that leadership has never properly designed.
Five questions every healthcare CEO should ask
1. What is our true denial rate?
Executives should review denial rates by payer, service line, facility, denial category, dollar value, and clinical impact—not rely solely on an organization-wide average.
2. How many denials are preventable?
Eligibility errors, missing authorizations, incomplete documentation, coding inconsistencies, and untimely filing should be analyzed separately from medical-necessity disputes.
3. How long are patients waiting?
Organizations should measure the time between a clinical recommendation, authorization request, payer decision, appeal, and delivery of care.
4. Where is AI influencing the decision?
Leaders should know whether algorithms are identifying claims for review, recommending denials, predicting medical necessity, generating appeal responses, or prioritizing work queues.
5. Who remains accountable?
There must always be a clearly identified human decisionmaker who can review the complete clinical picture, explain the decision, correct an error, and intervene when automated logic fails.
The solution is not simply to process denials faster
Healthcare does not need a more efficient system for repeatedly rejecting and resubmitting information.
It needs a more intelligent system that prevents avoidable denials, identifies missing requirements before services are delivered, communicates coverage rules clearly, and gives clinicians and patients a meaningful opportunity to correct inaccurate decisions.
That requires:
- Real-time eligibility and benefit verification
- Electronic prior authorization
- Standardized clinical-data exchange
- Strong clinical documentation
- Better integration between clinical and revenue-cycle systems
- Transparent denial-reason reporting
- Rapid and accessible appeal processes
- Responsible AI governance
- Continuous workforce training
The executive imperative
Healthcare leaders cannot treat rising premiums and denial rates as unrelated issues. Together, they create a damaging public perception: people are paying more for coverage while becoming less certain that the coverage will be there when they need it.
That perception weakens trust in insurers, employers, providers, technology, and the healthcare system itself.
The organizations that lead the next era of healthcare will not be those that merely automate the existing process. They will be the organizations that use interoperability, clinical intelligence, and responsible AI to make coverage decisions more accurate, timely, transparent, and humane.
The central question for every CEO should be:
Are we using technology to remove barriers to appropriate care—or are we simply building a faster and more sophisticated barrier?
References
- American Medical Association. (2026). 2025 AMA prior authorization physician survey. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
- Centers for Medicare & Medicaid Services. (2024). CMS interoperability and prior authorization final rule (CMS-0057-F). https://www.cms.gov/initiatives/burden-reduction/overview/interoperability/policies-regulations/cms-interoperability-prior-authorization-final-rule-cms-0057-f
- Centers for Medicare & Medicaid Services. (2024). Appealing health plan decisions. https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/appealing-health-plan-decisions
- Centers for Medicare & Medicaid Services. (2024). Has your health insurer denied payment for a medical service? You have the right to appeal. https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/appeals06152012a
- KFF. (2025). 2025 employer health benefits survey. https://www.kff.org/health-costs/2025-employer-health-benefits-survey/
- KFF. (2026). Claims denials and appeals in ACA Marketplace plans in 2024. https://www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/
- U.S. Senate Permanent Subcommittee on Investigations. (2024). Refusal of recovery: How Medicare Advantage insurers have denied patients access to post-acute care. U.S. Government Publishing Office. https://www.govinfo.gov/app/details/GOVPUB-Y4_G74_9-PURL-gpo234149
- Centers for Medicare & Medicaid Services. (2024). CMS interoperability and prior authorization final rule: Fact sheet. https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-prior-authorization-final-rule-cms-0057-f