Insurance Claim Denials: The Impact on Patient Care and Advocacy
In 2026, Mathew Evins, a marketing executive, faced significant challenges when his health insurer denied coverage for necessary back surgery. Despite medical recommendations, the insurer insisted on additional physical therapy before revisiting the authorization for surgery. This delay, emblematic of AI-driven prior authorization delays, extended over several months, worsening his condition and complicating his pursuit of effective treatment.
Across the U.S., individuals frequently encounter insurance claim denials, with industry data indicating that approximately 20% of claims face rejection, posing a significant barrier to patient care. In response, companies such as Sheer Health have sprung up to assist policyholders in navigating these complexities. Co-founded by Jeff Witten and Ben Howard, Sheer Health provides an advocacy service for managing insurance claims, offering comprehensive claims processing management for a monthly fee or a portion of recovered funds.
Sheer Health's intervention proved beneficial for Evins, enabling him to eventually secure surgical approval after prolonged struggles. The company's proactive approach included detailed policy reviews and collaboration with healthcare providers to expedite necessary approvals. This case highlights the broader scrutiny the insurance market faces regarding the efficiency and transparency of claims processing.
According to AHIP, a national trade group, collaboration among health plans, providers, and pharmaceutical companies is crucial for simplifying patient care pathways and maintaining affordability. Katherine Hempstead, a senior policy officer at the Robert Wood Johnson Foundation, acknowledges the role of firms like Sheer Health in tackling systemic issues, but their necessity underscores the inefficiencies within healthcare. Evins’ experience highlights the profound impact of insurance decisions on patient health outcomes, emphasizing the importance of responsible insurer actions in determining coverage.