Recently, the U.S. House Committee on Education and Workforce, which has jurisdiction over employer-sponsored (ERISA) health plans, published a report titled Denied: How the Health Care Industry Stacks the Deck Against Working Families (PDF). This report, authored by staff for the Committee’s Democratic members, shows that employer-sponsored health plans are denying claims at high rates, which can disrupt patient care and impact revenues for medical practices.
Congressman Bob Onder, MD (R-MO-3), author of the Allergy and Asthma Patient Protection (AAPP) Act, serves on the Education and Workforce Committee. The AAPP Act is intended to address commercial payer issues specific to the allergy specialty. Although the report was published by Committee’s Democratic staff, the report’s findings strongly align with the purpose of the AAPP Act. We hope this shared interest will help support bipartisan sponsorship for the AAPP Act once it is officially introduced.
The entire report is long; a brief summary follows.
The report argues that insurance companies and third-party administrators increasingly use prior authorization, claim denials, and utilization management tools to delay or prevent care. The authors contend that many Americans with employer-sponsored insurance believe they are protected from major medical expenses, only to discover that treatment approvals, medications, or procedures can still be denied after significant delays and paperwork. The report frames this as a growing consumer protection issue rather than simply an administrative inconvenience. The report states that most Americans get their insurance through an employer-sponsored health plan, which adds to the importance and urgency of these issues.
A major focus of the report is prior authorization. Committee staff cites examples of patients experiencing delayed cancer treatment, postponed surgeries, interrupted chronic disease management, and difficulty obtaining specialty medications because insurers required repeated approvals or additional documentation. The report argues that these processes create substantial burdens not only for patients, but also for physicians and medical practices, which must devote an increasing amount of staff time to navigating insurance requirements instead of direct patient care. A recent federal regulation intended to improve the prior authorization process would not apply to employer-sponsored plans. However, the report emphasizes that prior authorization is a major issue for these plans in addition to those impacted by new federal regulations.
Another theme throughout the report is the financial impact on working families. Even insured patients may face unexpected out-of-pocket expenses, medical debt, or treatment abandonment after denials or prolonged approval delays. The report contends that these problems disproportionately affect patients with chronic illnesses and those who lack the time, resources, or health literacy needed to navigate complicated appeals systems. It also highlights concerns that administrative complexity may widen existing disparities in access to care.
The report also criticizes the lack of transparency surrounding denial practices. According to the findings, many employer-sponsored health plans do not publicly disclose denial rates, appeal outcomes, or how algorithms and outside vendors are used in coverage determinations. The authors argue that consumers often cannot easily determine why care was denied or how likely an appeal is to succeed. The report further suggests that federal regulators currently lack sufficient oversight tools and reporting requirements to adequately monitor these practices.
Denials, prior authorizations and excessive documentation requests force providers to dedicate time and financial resources to fight for every dollar they are owed for medically necessary covered services. For allergists, this could mean fighting health plans for a $12-$15 allergy shot claim. At a certain point, it costs more money to appeal denied claims than the actual claim amount. When allergists cannot manage a patient’s asthma or allergies with cost-effective, disease modifying allergy shots, patients might end up on expensive biologics that cost these same health plans tens of thousands of dollars. The AAPP Act is intended to help allergists by requiring commercial health plans to cover allergy shots consistent with CPT guidelines, prohibits arbitrary medically unlikely edit (MUE) limits, and requires coverage of the build up phase and diluent, among other things.
The report concludes by calling for stronger federal oversight, more transparency requirements, faster and fairer appeals processes, and tighter regulation of prior authorization practices. While the report reflects the perspective of Democratic committee staff, many of the concerns raised overlap with issues physicians across specialties have raised for years. For allergists, the debate is especially relevant as Congress continues discussing reforms such as the AAPP Act and broader efforts to reduce barriers between patients and prescribed treatments.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
