Patients who appeal a denied insurance claim win about half the time, and in some plans they win nine times out of ten.
The usual assumption is that a denial is a decision. John Tozzi's reporting says it is closer to a first offer: most people never contest it, and the ones who do are more likely to win than to lose.
"If your denials are being overturned nine out of ten times, why are you denying those patients?"
Tozzi covers healthcare for Bloomberg News and built the analysis with colleagues from data the insurers were required to disclose for the first time under federal rules.
The full segment is covered here so you can skip it.
Here are the 6 numbers that matter.
👤 Guest: John Tozzi, Healthcare Reporter at Bloomberg News, in studio
🎙️ Hosts: Jess Minton and Alexis Christophorus, anchoring Bloomberg Businessweek Daily in place of its regular hosts
📰 Published: 14 September 2026 on the Bloomberg Businessweek Daily podcast
🟣 Apple Podcasts | 🔗 Episode page | ⏱️ length not available
Key Takeaways
Appealing a denied prior authorization works about half the time, and in some plans nine times out of ten
Most patients never appeal, which is what makes the win rate possible
The appeal goes back to the company that issued the denial
An outside reviewer enters only at a later stage, and the decision stays the insurer's
The data behind all of this is new, and exists only because federal rules forced the disclosure
A service where 98% of requests are approved raises the question of why it needs approval at all
Nobody can yet say which conditions get denied most, because the disclosure does not break the numbers down
UnitedHealthcare abolished prior authorization in the late 1990s and brought it back in the 2000s when costs rose
1. Half of Appeals Are Won
Jess Minton introduced the story off the Bloomberg terminal, saying patients often win if they actually fight a denial and that the process is complex enough that people run into it constantly. Alexis Christophorus added that it can pay off if you go through the effort.
Tozzi started with what prior authorization is: "Your health plan says you kind of need to get approval before getting a treatment or a medication, right? And when that happens, there's basically, if it's denied, people have a chance to appeal, and they have multiple rounds of appeals."
The finding is a gap between behavior and odds. Tozzi said that "most people don't appeal denials, but we analyze some new data from the insurance companies that show when they do, they often win about half the time, according to the data we found from large insurance companies. In some plans, they win nine out of 10 times or more."
The reporting exists because of a disclosure rule rather than a leak: "And this is an analysis that myself and colleagues here did based on new data that the companies were required to disclose under federal regulations."
Christophorus read the top-line figure out of the article, that five large publicly traded insurers "denied more than 10% of standard prior authorization requests last year for most Medicare, Medicaid, and Affordable Care Act plans"
Tozzi noted that the details of how many rounds of appeal a patient gets differ depending on the product
2. Appealing to the Denier
Christophorus's first question was the practical one: who is the patient actually appealing to?
The answer is the same company that said no: "Well, they're appealing to the insurance company, right? So the insurance company is the one who's saying, this service or medication is approved or it's denied, and it could be denied for different reasons."
The two reasons he named are very different in kind: "It could be denied because they think it's not medically necessary. It could be denied because the doctor hasn't submitted the right documentation needed to approve it."
An independent reviewer exists but arrives late and does not take the decision away: "Sometimes on an appeal, it goes to an external third-party reviewer at a certain point, but it's the insurance company's decision."
3. How Long It Takes
Asked how long an appeal takes on average, Tozzi said he did not have that number and then gave both sides of the dispute about it.
The industry's own claim is speed, measured against a rule: "You know, the health insurers point out that, they make decisions on these prior authorization requests quickly within a day. On average, they say, and they say that's faster than the federal requirements."
What reporters hear from the other end does not match: "We hear from doctors and patients sometimes that doesn't always line up with their experience, and it can be much longer for some people, particularly with complicated cases."
He was explicit that he did not know the figure offhand rather than estimating one
4. Why Deny at All?
Christophorus put the obvious follow-up: if so many appeals succeed, why were the claims denied in the first place, and do insurers need to look hard at how they assess them?
Tozzi set the context first, and it is a long-running fight: "The insurance industry has been under pressure from the public, under pressure from regulators who say these prior authorizations are too burdensome. They have committed to voluntary actions to sort of simplify and automate the process and reduce the number of services that require prior authorization."
The approval rate is what makes the question sharp: "But it is a broader conversation around, if you're an insurance plan and you're approving 98% of prior authorization requests for a particular service, why is it subject to prior authorization, right?"
And the overturn rate makes it sharper still: "If your denials are being overturned nine out of ten times, why are you denying those patients?" Those, he said, are the questions this data lets people ask
5. What the Data Won't Show
Asked whether some kinds of care — terminal illness, chronic conditions — get denied more often than others, Tozzi's answer was that nobody can say yet.
The disclosure stops short of the question everyone wants answered: "I think one of the sort of blind spots in the data that the government required companies to disclose is we sort of know at a high level, this percentage was denied, this percentage was approved, this percentage was overturned, but we don't know, well, were all those denials for, particular types of disease or particular types of conditions."
"So there is still a lot of, a lot we don't know about how this process works in practice," he said
On whether insurers are simply getting it wrong, he described a genuine disagreement rather than an error rate: "I think clinicians will often say, that insurers are not up to date on the guidelines."
The sharpest version of it is in oncology: "And, particularly with cutting edge, advanced cancer treatments, we hear sometimes that insurance companies are relying on, out of date guidelines, or they just disagree with the clinical judgment of, a physician."
He would not generalize, and named the structural conflict instead: "I think it's hard to speak in generalities around this, but this is a real source of tension in the health care system, right, where the company that is deciding whether or not it will pay for your care says, no, this is not warranted based on X, Y, Z evidence. And the doctor who's actually in front of you treating you says, yes, it is, and here's why."
6. The 1990s Experiment
Christophorus pulled a piece of history out of the article: UnitedHealthcare abolished prior authorization in the 1990s and brought it back about a decade later.
Tozzi said the backlash of the period is the context most people have forgotten: "In the late 90s, when there was sort of really widespread backlash to managed care and to all these sorts of cost control measures from HMOs and insurance companies" the company did away with the practice, and revived it in the 2000s after medical costs went up
The reporting includes the executive who was there. Archelle Georgiou, the company's chief medical officer at the time it was scrapped, has since left and now advises healthcare companies
She is now working from the same disclosure data, and arguing for a more targeted and less burdensome version of the practice rather than its abolition
Bonus Insights
Christophorus's closing note was that the outcome is encouraging only for patients who have both the time and the wherewithal to fight, which she acknowledged many do not
Minton framed the story at the top as one people run into constantly, and Christophorus described the appeals process as a set of loopholes that rewards the work put into it
Tozzi was in studio rather than on a remote line, and the anchors said the subject warranted bringing him back
Tozzi's bottom line is that prior authorization now has a public evidence base for the first time, and the first thing that evidence shows is that a large share of denials do not survive being challenged — which turns the question from whether patients should appeal into why the denials were issued.
Products, Companies & Tools Mentioned
UnitedHealth Group (Abolished prior authorization in the late 1990s during the managed-care backlash and revived it in the 2000s as medical costs rose; its chief medical officer at the time is a source in the reporting)
Medicare, Medicaid and Affordable Care Act plans (The three plan types the disclosed denial rates cover, where five large publicly traded insurers denied more than 10% of standard requests last year)
Archelle Georgiou (Former chief medical officer of UnitedHealthcare, interviewed for the story; now a strategic advisor arguing for a more targeted, less burdensome version of prior authorization)
Books & Resources Mentioned
The Bloomberg News analysis of prior authorization denials and appeals (Written by Tozzi and colleagues from newly disclosed insurer data; the source of every figure in this segment)
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