ERs become front doors to care as insurers deny coverage, fueling delays and costs

Emergency rooms have become the last functioning front doors to American healthcare, a perspective shared by emergency physicians in major cities. When insurers deny or delay authorization for tests or treatments, diagnoses stall and patient anxiety rises. In practice, the ER has increasingly become the default outpatient clinic for non-life-threatening conditions blocked by insurers, where care can begin immediately rather than be impeded by prior authorizations. Medical debt from insurance denials is a growing concern, with a recent national report estimating that nearly one in five American families carries medical debt. A 2023 study of Medicaid enrollees found that those who faced procedural denials were about 20% more likely to visit the ER within 60 days.

Internal documents reported by ProPublica show that Cigna doctors denied care for more than 300,000 patients using mass denials, spending an average of 1.2 seconds on each case. What was meant to curb unnecessary tests and care has, critics say, metastasized into a navigational obstacle course that delays diagnosis and drives up costs. The denial process has blocked tests such as magnetic resonance imaging that could reveal serious surgical conditions, leaving patients waiting for care they cannot obtain elsewhere.

Some patients have been able to leverage public attention to overturn decisions. Health policy professor Miranda Yaver described her own experience after Aetna denied her care; after hours on hold, she turned to social media and watched the company reverse a $30,000 denial. Others have used Twitter and other platforms to push insurers toward reversing decisions, though advocates caution that social media wins are not a substitute for durable policy changes.

Policy experts and patient advocates say the path forward requires concrete reforms. They call for clear, patient-friendly appeals processes and real accountability from insurers at the state and federal levels. They urge insurers to provide transparent, real-time dashboards showing denial rates and time-sensitive appeal portals. They argue for federal guardrails to protect patients from needless denials and for a system that prioritizes timely access over paperwork.

Time to act, the critics say, is now. In a system where insurers can deny care in as little as a moment, reform must move with comparable speed to prevent patients from seeking care only in emergency rooms. The effort to reduce avoidable ED visits will require sustained legislative action, aggressive enforcement, and a commitment to placing patients ahead of paperwork.