Clarity Mutual
A policyholder-owned mutual insurer that publishes its claim denial rates, underwriting criteria, and payout ratios publicly, and doesn't tie adjuster pay or bonuses to how many claims they deny.
Health Insurance
The Algorithm Denies Your Claim. No Doctor Ever Reads the File.
In 2023, ProPublica found Cigna doctors spent an average of 1.2 seconds "reviewing" each of 300,000 claims over two months, using a system called PxDx to deny them in batches without opening a chart. UnitedHealth's naviHealth subsidiary faces a class-action lawsuit alleging its nH Predict algorithm was used to cut off Medicare Advantage rehab coverage even though more than 90% of appealed denials were later overturned. This page is about fixing that: insurers should have to show their work, and a denial should mean a person actually looked at your case.
The gap between denied and appealed
Cigna's PxDx system
Internal spreadsheets tracked by ProPublica, covering two months in 2022.
Claims denied
300,000
Average review time
1.2 seconds
HealthCare.gov marketplace, 2023
KFF's analysis of federally reported claims data.
In-network claims denied
~20%
Denials consumers appealed
<1%
Industry scale
Illustrative in-network claim denials so far this year, scaled from KFF's ~86M/year marketplace figure.
This year so far
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How coverage gets denied without you knowing why
Doctors Signing Off in Bulk, Not Reading Charts
ProPublica's 2023 investigation into Cigna's PxDx (procedure-to-diagnosis) system found a single medical director denying as many as 60,000 claims in a month, spending an average of 1.2 seconds on each. A former Cigna physician described the process as clicking "submit" on 50 claims at a time, without opening the patient's file or applying medical judgment to a specific case. Cigna disputed the characterization, but the practice has drawn multiple lawsuits and a congressional inquiry.
An Algorithm With a 90% Error Rate, Used Anyway
A class-action lawsuit against UnitedHealth alleges its naviHealth subsidiary used an AI tool called nH Predict to determine how much post-acute rehab care Medicare Advantage patients would receive, and that when patients appealed those denials, more than 90% were overturned. Reporting by STAT News found internal pressure on case managers to keep patient stays close to the algorithm's predictions. UnitedHealth says the tool is meant to inform, not decide, coverage.
One in Five Claims Denied, and Almost Nobody Appeals
KFF's analysis of 2023 HealthCare.gov marketplace data found insurers denied about 20% of in-network claims, roughly 86 million denials in a single year. Consumers appealed only 376,508 of them, an appeal rate below 1%. Of the claims that were appealed, insurers still upheld 56% of their own denials, which is exactly why a low appeal rate matters: most people who could win an appeal never file one.
The Law Already Requires Disclosure. Enforcement Doesn't Happen.
A provision of the Affordable Care Act has required insurers to publicly report claim denial rates and reasons since 2010. For over a decade, KFF and other researchers have found the reported data incomplete, inconsistently categorized, or missing outright for many plans, with essentially no penalty for insurers that don't comply. The rule exists on paper. It has never been enforced the way it was written.
Prior Authorization as a Built-In Delay
The American Medical Association's December 2024 survey of 1,000 physicians found 93% report that prior authorization delays care patients need, 29% report it has caused a serious adverse event for one of their patients, and 82% say it can lead patients to abandon treatment altogether. Clinicians and their staff complete an average of 39 prior authorizations a week, burning around 13 hours of clinical time that could otherwise go to patients.
No Way to See the Price Before You're Billed
Even with federal hospital and insurer price-transparency rules on the books, the negotiated rate you'll actually be charged for a given procedure, under your specific plan, at your specific provider, is frequently impossible to find before you receive care. Insurer cost-estimator tools are often missing for out-of-network care, out of date, or simply don't cover the service in question, so patients agree to treatment with no real idea what it will cost them until the bill and the denial letter arrive together.
What Actual Reform Looks Like
Phase 1: Require insurers to disclose, per claim, whether a human clinician reviewed the specific case before a denial, not just that "a review occurred." Phase 2: Actually enforce the ACA's existing denial-rate reporting requirement, with real penalties for incomplete or missing data. Phase 3: Cap prior-authorization decision times and require insurers to publish their approval and overturn-on-appeal rates by procedure. Phase 4: Require a binding, plan-specific price estimate before non-emergency care, so the bill isn't the first place a patient learns what something costs.
Fair, Transparent Insurance Is Possible
None of this is inherent to insurance as a product. A policyholder-owned insurer that publishes its denial rates, doesn't tie adjuster pay to how many claims they reject, and explains a denial in plain language rather than a form letter can run at scale. See the Community Solutions and companies below for groups working on exactly that.
Community Solutions
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Companies Working On This
Submit a CompanyApproved companies and organizations addressing this problem. Anyone can submit one for review.
