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Matt dives into a specific healthcare topic to help those in the industry, and those outside of it, better understand the market drivers causing today’s healthcare challenges.
The Denier Owns the Reviewer
An insurer can own the company that reviews the insurer’s own prior authorization requests. When that corporate family says no, the money stays inside the corporate family. Run that structure past anyone who regulates any other market in this country and watch what happens to their face. No judge hears a case they hold a financial stake in. No auditor signs off on their own books. No referee bets the game. Healthcare built the exception anyway, wrapped it in three euphemisms, and has defended it for twenty years. Hannah Garden-Monheit ran the Federal Trade Commission’s Office of Policy Planning from December 2023 through January 2025. She wrote her prior authorization paper this August, after UnitedHealthcare denied her father’s post-amputation rehabilitation twice. Michael Monheit died in February. He never received a prosthetic.
“Nobody lets a party judge its own case and pocket the verdict.”
What the Paper Actually Says
Garden-Monheit and her co-author Emma Freer published the brief through the American Economic Liberties Project, and the frame matters more than the topic. They argue antitrust structure, not benefit design. Nobody in the paper asks insurers to review requests more carefully or to publish better criteria. They ask why the entity that profits from a denial gets to issue the denial. The numbers behind the question come from the government’s own reporting. Medicare Advantage insurers processed nearly 53 million prior authorization determinations in 2024, roughly 1.7 per enrollee. Traditional Medicare processed 628,000, roughly 0.02 per enrollee. Same beneficiaries, same medicine, eighty-five times the friction. Insurers denied 4.1 million of those requests in full or in part, a rate of 7.7 percent. Enrollees and their physicians appealed just 11.5 percent of the denials. Medicare Advantage insurers then overturned more than 80 percent of what they reviewed on appeal. Sit with those last two numbers together. Four out of five denials that anyone bothered to challenge fell apart on a second look, and almost nine out of ten never got challenged at all.
Four out of five denials that anyone bothered to challenge fell apart on a second look, and almost nine out of ten never got challenged at all.
The core proposal reads in one sentence: prohibit common ownership between insurers and the entities that adjudicate prior authorization.
Write it into statute.
Where narrow, evidence-based prior authorization survives, the paper stacks guardrails on top of it.
An independent third party decides, with no insurer affiliation.
Artificial intelligence may approve a request and may never deny one.
A board-certified physician in the same specialty conducts peer-to-peer review.
Urgent decisions land within 24 hours and routine ones within seven days, against the current CMS standards of 72 hours and 15 days, and
A missed deadline converts to automatic approval.
No retroactive claim denial after an approval. Read that list as a description of what the current system permits, because every item on it names something happening right now.
Physicians already priced the cost. The American Medical Association surveyed 1,000 practicing physicians in December 2025.
Ninety-five percent reported that prior authorization delays care.
Seventy-nine percent reported that it drives patients to abandon treatment at least sometimes.
Twenty-six percent reported a serious adverse event, and
8 percent reported a patient death, disability, or permanent damage.
The average physician processes 40 requests a week and spends 13 hours doing it.
Ninety-four percent said the process worsens burnout, and
60 percent said they expect artificial intelligence to push denial rates higher.
Now put the Monheit family back in the frame. In June 2024 reporting, Medicare Advantage insurers denied 54 percent of prior authorization requests for inpatient rehabilitation facilities and 65 percent for long-term care hospitals, against an overall denial rate under 8 percent. His care team at Johns Hopkins fought the denials alongside the family. The insurer cited his cancer diagnosis without acknowledging the amputation, then argued he lacked medical necessity because he could hop on one leg from his hospital bed to a chair. After more than a week burned in the hospital, the family stopped appealing to protect the time they had left. He worried United would retaliate while he still needed the coverage for his cancer treatment.
Archo’s ELAVAY research has asked patient advocacy organizations, professional societies, and community groups the same core question every year since 2015, across more than 20 disease states annually: how do the companies that call you a partner actually behave. The decade-long finding is a gap. Companies rate their own advocacy performance well. The organizations they name in the partnership slide describe something different.
Nobody Says It Out Loud in the Access Meeting
Start with the ownership map, which sits in public filings and requires no accusation to state.
UnitedHealth Group owns UnitedHealthcare and Optum.
Optum bought naviHealth in 2020 for a reported price above a billion dollars, retired the naviHealth name in October 2023, and folded the post-acute review business into its home and community care unit.
CVS Health owns Aetna.
The Cigna Group owns Evernorth.
Now the language. Utilization management. Clinical appropriateness review. Medical necessity determination. Three phrases built to describe a denial without ever using the word, and every one of them shows up in advocacy decks written by people who know better. On the manufacturer side, look at where the money sits. Hub services and patient support programs get funded as a cost of doing business against prior authorization friction. That line item exists because the friction exists. Almost no commercial team has modeled what happens to the line, the vendor contract, or the time-to-therapy forecast if the friction changes shape rather than disappearing.
The advocacy failure runs deeper and nobody names it in the room. Organizations sit on denial data across thousands of member cases. Intake logs, appeal outcomes, the calls that come in every week. Then they publish a patient story for an awareness day and let the rest rot in a CRM. A legislative staffer drafting language this fall needs a case count, a denial reason distribution, and an average appeal duration. Most advocacy organizations could produce all three by Friday and choose not to.
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What the Top Performers Do Differently
They aggregate denial data continuously instead of collecting stories after a crisis, and they can produce a denial rate, an average appeal duration, and a case volume on request rather than on a two-week scramble.
They seat advocacy in the room where access strategy gets set, early enough in the planning cycle to change a decision, not in the readout that follows. The organizations ELAVAY ranks at the top show that pattern consistently, and the median organization runs the identical meeting one gate too late.
They engage during the drafting window, because a blueprint becomes a bill when advocates bring evidence while the language stays soft. After introduction the text hardens and the work degrades into lobbying.
And they tell leadership the truth about their external standing instead of reporting relationship health from inside the building, which is the single behavior that separates the two groups more than any other.
A blueprint becomes a bill when advocates bring evidence while the language stays soft.”
Show Up Before the Language Hardens
Advocacy leaders, pull your denial data this quarter. Case count, denial reasons, appeal durations, outcomes. Compress it into two pages a legislative staffer can read in four minutes, because the staffer will not read six.
Commercial and market access leaders, stress test the access model against a world where prior authorization changes structurally rather than incrementally. Ask out loud what your time-to-therapy forecast assumes about denial rates, and find out whether anyone in the building can answer.
Take the Advocacy Influence Diagnostic. Five minutes, free, anonymous. It returns an Advocacy Visibility Index and a Strategic Risk Score, which tells you whether your advocacy function sits close enough to the decision to matter in a fight like this one. The 2025/2026 ELAVAY Report is available now, and fielding for 2026/2027 opens in October. Reach me directly at [email protected].