From The Desk of

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. 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.

What the Paper Actually Says

Garden-Monheit and her co-author Emma Freer published the brief through the American Economic Liberties Project. They argue antitrust structure, not benefit design. The numbers behind the question come from the government’s own reporting. Medicare Advantage insurers processed nearly 53 million prior authorization determinations in 2024. Insurers denied 4.1 million of those requests, a rate of 7.7 percent. Enrollees appealed just 11.5 percent of the denials. Medicare Advantage insurers then overturned more than 80 percent of what they reviewed on appeal.

• The core proposal: prohibit common ownership between insurers and the entities that adjudicate prior authorization.

• An independent third party decides, with no insurer affiliation.

• Artificial intelligence may approve a request and may never deny one.

• A missed deadline converts to automatic approval.

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. Twenty-six percent reported a serious adverse event, and 8 percent reported a patient death, disability, or permanent damage.

What the Top Performers Do Differently

• They aggregate denial data continuously instead of collecting stories after a crisis.

• They seat advocacy in the room where access strategy gets set, early enough in the planning cycle to change a decision.

• They engage during the drafting window, because a blueprint becomes a bill when advocates bring evidence while the language stays soft.

• They tell leadership the truth about their external standing.