The New Push: Don't Just Reform the System — Make Them Pay

State-level prior authorization reforms were a start. Now comes the harder fight.

Mark Cuban and a coalition of physicians are calling for direct legal accountability for health insurers whose claim denials result in patient harm, according to The Hill. Not new reporting requirements. Not appeals process tweaks. Actual liability.

The argument is simple: right now, insurers deny claims, patients suffer, and the insurer walks away clean. That asymmetry has to end.

The Numbers Are Brutal

A KFF study of ACA marketplace plans found that insurers denied an average of 17% of claims in 2021 — even when patients saw in-network doctors the insurer itself approved, according to PBS NewsHour/KFF Health News reporter Elisabeth Rosenthal.

You pick a doctor from the insurance company's own approved list. You do everything right. And they still deny nearly one in five claims.

One unnamed insurer rejected 49% of claims in 2021. Another hit 80% in 2020. Those aren't outliers. That's a business model.

The Algorithm Factory

Insurers aren't staffing these denial decisions with experienced physicians carefully reviewing charts. According to Rosenthal's reporting for PBS/KFF Health News, companies are deploying computer algorithms or personnel with little relevant medical experience to issue rapid-fire denials — sometimes rejecting claims in bulk, without ever opening a patient's file.

One company reportedly had a job title called "denial nurse." That's not a healthcare role. That's a revenue strategy.

Dean Peterson of Los Angeles told KFF Health News he was shocked when his insurer denied payment for a heart procedure after a cardiac arrhythmia caused him to faint with a heart rate of 300 beats per minute. The procedure cost $143,206. The insurer had pre-approved it. They denied it anyway.

The Federal Government Dropped the Ball — Years Ago

The Affordable Care Act explicitly tasked the Department of Health and Human Services with tracking claim denial rates — both on ACA marketplace plans and employer-sponsored plans — because lawmakers anticipated insurers would compensate for new coverage requirements by ramping up denials.

According to Rosenthal's analysis published by PBS News, HHS has NOT fulfilled that assignment. The monitoring mandate exists on paper. The actual monitoring does NOT.

This isn't a Trump problem or a Biden problem exclusively. It's a years-long bureaucratic failure that crossed multiple administrations. Nobody forced HHS to do its job, and nobody in the press made a serious sustained issue of it until patients started dying waiting for approvals.

Why Appeals Don't Fix This

The data shows patients appeal denials only once in every 500 cases, according to KFF's research cited by PBS News. That's not because the denials are legitimate. It's because the appeals process is exhausting, confusing, and designed to outlast sick people.

Insurers know this. Bet on patient attrition and you win almost every time.

When patients do appeal, overturn rates are often significant — meaning the original denial was wrong. But most patients never get there. They either pay out of pocket or skip the care entirely.

Skipping medically necessary care isn't a paperwork inconvenience. It's a health outcome. Sometimes a fatal one.

What Cuban and the Physicians Actually Want

The accountability push coming through The Hill centers on a legal standard: if an insurer denies care that a licensed physician determined was medically necessary, and the patient is harmed as a result, the insurer should face the same liability exposure a negligent physician would face.

Right now, insurers are largely shielded from that liability under ERISA — the federal law governing employer-sponsored plans — according to multiple legal analyses. State courts have limited reach. Federal courts have historically given insurers wide latitude.

Changing that requires either Congress acting or courts reinterpreting existing law. Neither is fast. Neither is easy. But the political pressure is building from an unusual coalition: celebrity entrepreneurs, the physician community, and a public that is genuinely furious.

What Mainstream Coverage Is Getting Wrong

Most outlets are framing this as a partisan healthcare debate — left wants more regulation, right wants less. That's a misreading.

This isn't about government-run healthcare versus the free market. This is about contract fraud. A patient pays premiums. The insurer agrees to cover medically necessary care. The insurer then uses algorithms to deny that care at scale while pocketing the revenue.

That's a protected oligopoly exploiting regulatory capture. Common-sense conservatives should be just as outraged as anyone — taxpayer-funded programs like Medicare Advantage have the same denial problem, and insurers are collecting federal dollars while delivering less care.

The Accountability Question

Thirty-one states reforming prior authorization rules was real progress. But process reform without accountability is incomplete.

If an insurer's algorithm denies a heart patient's pre-approved procedure and that patient dies, someone should answer for it. Right now, nobody does.