We docs tend to be oddly quiet about a growing contributor to physician burnout: insurance company overreach. Raising the health care water temperature ever so slowly but consistently, major payers are replacing the formerly independent clinical decision-making process with financially driven algorithms right before our eyes. The physician frog is boiling. In a recent survey conducted by the American Hospital Association, over 80% of physicians said that insurance policies negatively affected their ability to practice medicine, and 56% of nurses reported significantly decreased job satisfaction because of it.
We’re burned out of talking about clinician burnout. It’s over-covered. Increasing administrative burden, decreasing patient-facing time, shrinking support structures, declining compensation, longer hours, EMR checkbox hell, bottomless in-baskets, non-medical switching, and prior authorizations required for every breath we take. These are the well-known, well-documented realities of 21st century desktop medicine. Recent data from CMS reveals a steady increase in prior authorizations within Medicare Advantage (MA) plans. Specifically, prior authorization requests rose from 37 million in 2021 to nearly 50 million in 2023. An April 2025 study conducted by the American Medical Association found that the average practice completes 39 prior authorizations per week per physician, consuming approximately 13 hours per week. If you are a clinician working the typical eight hour per day five days per week job, that is one new prior authorization request every hour. To this end, 40% of physicians now have staff who work exclusively on prior authorizations. And an increasing number of outpatient clinicians are now adding additional “administrative fees” to patient bills to cover these expanded administrative insurance-imposed costs, fueling unneeded animosity, frustration, and distrust within the clinician-patient relationship.
We collectively loathe these barriers. We frequently commiserate over them in conversation, in writing, and on social media. The shared struggles bind us together. But while burnout and desktop medicine are some of our favorite watercooler topics, we don’t talk very openly about insurance company overreach. Why?
Insurance companies know they can increase their control over clinical decision-making with almost complete impunity — not because they think us doctors don’t notice (we do), but because they know we can’t speak out. If you still see patients and take insurance, you can’t bite the hand that also unilaterally controls your patient access, your patient claims submissions, and thus, your own professional future. No one knows this better than Dr. Elizabeth Potter. As a prominent Texas based breast cancer plastic surgeon, Dr. Potter posted a video in January of 2025 detailing an incident where UnitedHealthcare allegedly called her “urgently” mid-surgery to question her about an overnight hospital stay that had already been pre-approved. After the video went viral, the insurer sent her a formal legal letter from a high power law firm threatening to sue her for defamation if she did not take it down immediately and issue a formal apology. She did not.
The upshot was that a year later, United still refuses to admit her facility into their network. Without being in-network with one of the largest payers, Dr. Potter now struggles to keep her doors open. She states that it is only through public donations that she is able to still keep her cancer surgery center afloat. Dr. Potter’s story reverberates in our minds with a powerfully chilling effect: we stay silent. We all understand her struggles. But no one wants her fate.
Because insurance companies don’t actually see patients like we do, they are shielded from the often catastrophic consequences that their decisions can cause. Therapy denials can result in patient suicide. Imaging denials can lead to undetected, advanced cancer. Addiction treatment denials can result in patient relapses and overdoses. Insurance companies don’t witness these tragedies. We do. When you’re shielded from the negative consequences of your decisions, you’re more motivated, even emboldened, to continue making them.
I write regularly about things that either inspire or anger me in health care. Increasing payer domination over clinical decision-making is by far my biggest source of daily frustration. It’s the largest single factor contributing to my growing desire to leave the field completely. Yet I’ve never written a sentence about it (until now). I try to start. Then I envision the possibilities of being kicked out of a large payer network, and I quickly reach for the delete button.
Talking to other physicians behind closed doors, most feel this way. It’s the whispered stories over lunch, the quiet conversations in the hallway, the reddit threads, the TikTok videos. The NBC Nightly News recently started covering dubious health insurance decisions (including the Dr. Potter story) in their series “The Price of Denial.” Good for them! But they don’t get paid by insurance companies. We do.
What do we do when we have a front row view to all of this and we can’t speak up? I ponder this predicament daily. Take network adequacy. Most states have strict laws that require health insurance companies to provide sufficient clinician availability or “network adequacy.” These laws are designed to ensure patients can obtain timely and accessible care through their health insurance company. Sounds great in theory. But they aren’t enforced. One of the largest health insurers in the country has my personal cell phone number and personal email address listed on their online directory as an active, in-network clinician accepting new patients. I haven’t taken new patients in years. Despite this, I get 5-10 phone calls per week (and even more emails) from desperate patients looking for an addiction clinician. One mom looking for treatment for her son called me yesterday, pleading “We found you on the in-network clinician website. You are the only addiction psychiatrist in this state.”
Despite my multiple calls and emails requesting they remove me from a public website I never asked or agreed to be listed on, this health insurance company still refuses to take my information down. Why? As a specialist, I help to meet their network adequacy requirements on paper, but not in practice.
At the beginning of my career, I worked for a large HMO that didn’t allow patients to see out-of-network therapists. This is standard, run of the mill HMO practice. But the wait time to see an in-network therapist was 3-6 months. This HMO had approximately 100 in-network therapists for a patient population of 1 million lives, spread over three states. If you’re keeping track, that’s one therapist for every 10,000 people. When a patient requested an external therapy referral due to the excessive wait time, I was instructed to deny the referral, with the listed reason being “service available internally.” Technically speaking, therapy was available internally. But you’d never be able to access it. We received 20-30 requests for external therapy appointments daily. We denied almost all of them. The only patients “allowed” to see certain external therapists were those who had purchased the much more expensive HMO plan. Treatment was determined by money, while using a psychiatrist signature for denial to give the illusion of decision making based on clinical acuity. It was a true pay-to-play system hidden behind the mask of an MD stamp, to appear as if the determination was based on medical necessity versus finances.
While waiting months to see an in-network therapist, two of my patients committed suicide. Both had submitted requests to see an external therapist prior to their death. Both were declined due to “service being available internally.” One had even messaged an in-network therapist several times leading up to the suicide, desperately seeking a sooner appointment. The therapist responded with a link to the internal appointment booking website, where the next available appointment was three months out.
After the two suicides, I pleaded with the internal leadership to change the policy on external therapy referrals. I sent screenshots of the latter patient’s repeated therapy requests to the physician leaders and key decision-makers. Since network adequacy regulation was not a deterrent, surely these preventable deaths would prompt meaningful change. But leadership kept the ban on external therapy referrals after the two suicides, citing the financial implications of opening the network to external clinicians. They also insisted that I continue signing off on these denials as the head utilization management physician reviewer. That’s when I knew I needed to leave. I had zealously leapt into the organization eight years earlier as an excited young physician eager to improve access to mental health care and save lives. I left as an older, wiser, disillusioned doctor. I now understand that payers only conditionally share these goals — when it doesn’t cost them money.
Silence perpetuates harm. The Tuskegee Syphilis Study persisted from 1932 to 1972, with physicians quietly watching as hundreds of Black men were denied treatment. It was only when an insider finally spoke out (through the media) that public outrage forced change and new protections for patients.
So. What are we to do? While I don’t have the perfect answer, my gut tells me that the more we clinicians publicly talk about these behind-the-scenes challenges with payers, the easier it will be for all of us to collectively speak up. A statement often attributed to Martin Luther King Jr. is, “Our lives begin to end the day we become silent about things that matter.” I don’t know about you, but I’ve got to keep hope alive that we can somehow change the system. Or at least begin to make some cracks. At the very minimum, we must increase the dialogue around the topic. Because the alternative — a health care system increasingly dominated by finances at the expense of patients — is just too bleak.
What are your thoughts on insurance company overreach? Share in the comments.
Illustration by Jennifer Bogartz
