We asked Reddit: How often do you appeal Prior Auth denials?

Doctor filling out prior auth form

We turned to Reddit to hear directly from healthcare workers about their experiences with appealing insurance denials. You can read the whole thread for yourself, but we've summarized the main takeaways below.

The Overwhelming Consensus: Always Appeal

The most striking finding? Nearly every healthcare provider reports appealing prior authorization denials, with many citing success rates of 85-90%. As one psychiatrist put it, "100% of the time. I don't prescribe anything adventurous without good reason. If I've gone for it, I think there's reason for it and the patient will be worse off by giving in."

Key Insights from the Front Lines

1. Automatic Denials Are Common

Multiple providers reported that many denials appear to be automatic or "batched" without proper review. One notable example: Cigna was recently investigated for allegedly auto-denying 300,000 claims without proper review. As one provider noted, "They're probably using 'AI' to deny it, which is probably just a random number generator that denies 70% of things outright."

2. The Human Cost is Real

Particularly concerning were stories about denials for cancer treatment. As one provider explained, "Chemotherapy also has been advancing rapidly. Now there are problems when new consensus guidelines suggest neoadjuvant chemo rather than resection... Insurance denies. Now you can wait and fight or bow to less optimal but more accessible therapy that isn't even necessarily cheaper."

3. Time is a Major Factor

Healthcare providers consistently reported spending significant time on appeals:

  • Writing prior authorizations
  • Receiving denials
  • Writing disputes
  • Faxing documentation
  • Making multiple follow-up calls
  • Arranging peer-to-peer reviews

Successful Strategies from Providers

Documentation is Key

Several providers mentioned developing systems to improve their approval rates:

  • Keeping detailed records of all communications
  • Using specific terminology that insurance companies respond to
  • Building a library of successful appeal letters
  • Employing ChatGPT to help draft appeal letters
  • Maintaining templates for common scenarios

External Help is Available

Many providers mentioned outsourcing the appeals process:

  • Revenue cycle management companies
  • Dedicated prior authorization staff
  • Pharmacists specifically hired for authorization management
  • Third-party services that specialize in appeals

Looking Forward

The discussion reveals a healthcare system struggling with administrative burden, but also shows providers developing innovative solutions. Many are calling for systemic changes:

  • Standardization of the prior authorization process
  • Penalties for inappropriate denials
  • Automated approval for routine care
  • Reform of the peer-to-peer review process

Final Thoughts

While the current prior authorization system creates significant challenges, healthcare providers are finding ways to navigate it successfully. The key seems to be persistent advocacy combined with efficient systems for managing the appeals process. As one provider summed it up: "If I thought I could remove a year from an insurance company's executive's life on a per appeal basis, I'd probably appeal 100% of them."