The use of prior authorization has also increased in recent years.

This article was published on Monday, June 16, 2025 in KFF Health News.

By Lauren Sausser

BRIDGEPORT, W.Va. — By the time Eric Tennant was diagnosed in 2023 with a rare cancer of the bile ducts, the disease had spread to his bones. He weighed 97 pounds and wasn't expected to survive a year with stage 4 cancer.

Two years later, grueling rounds of chemotherapy have slowed the cancer's progress, even as it has continued to spread. But chemotherapy has also ravaged Tennant's body and his quality of life.

Recently, however, the 58-year-old had reason to hope things would improve. Last fall, his wife, Rebecca, learned of a relatively new, noninvasive procedure called histotripsy, which uses targeted ultrasound waves to destroy tumors in the liver. The treatment could extend his life and buy him more downtime between rounds of chemotherapy.

Early this year, Tennant's oncologist agreed he was a good candidate since the largest tumor in his body is in his liver. But that's when his family began fighting another adversary: their health insurer, which decided the treatment was "not medically necessary," according to insurance paperwork.

For months, Eric Tennant's health insurance refused to cover a cancer treatment recommended by his doctor, claiming the procedure was "not medically necessary," a common reason used by health insurers to deny care. (A portion of this photo is digitally blurred to protect patient privacy.)(NBC News)

Health insurers issue millions of denials every year. And like the Tennants, many patients find themselves stuck in a convoluted appeals process marked by long wait times, frustrating customer service encounters, and decisions by medical professionals they've never met who may lack relevant training.

Recent federal and state efforts, as well as changes undertaken by insurance companies themselves, have attempted to improve a 50-year-old system that disproportionately burdens some of the sickest patients at the worst times. And yet many doctors complain that insurance denials are worse than ever as the use of prior authorization has ramped up in recent years, reporting by KFF Health News and NBC News found.

When the Tennant family was told histotripsy would cost $50,000 and insurance wouldn't cover it, they appealed the denial four times.

"It's a big mess," said Rebecca Tennant, who described feeling like a pingpong ball, bouncing between the insurer and various health care companies involved in the appeals process.

"There's literally nothing we can do to get them to change," she said in an April interview with KFF Health News. "They're, like, not accountable to anyone."

While the killing of UnitedHealthcare chief executive Brian Thompson in December incited a fresh wave of public fury about denials, there is almost no hope of meaningful change on the horizon, said Jay Pickern, an assistant professor of health services administration at Auburn University.

"You would think the murder of a major health insurance CEO on the streets of New York in broad daylight would be a major watershed moment," Pickern said. Yet, once the news cycle died down, "everything went back to the status quo."

An Unintended Consequence of Health Reform?

Prior authorization varies by plan but often requires patients or their providers to get permission (also called precertification, preauthorization, or preapproval) before filling prescriptions, scheduling imaging, surgery, or an inpatient hospital stay, among other expenses.

The practice isn't new. Insurers have used prior authorization for decades to limit fraud, prevent patient harm, and control costs. In some cases, it is used to intentionally generate profits for health insurers, according to a 2024 U.S. Senate report. By denying costly care, companies pay less for health care expenses while still collecting premiums.

"At the end of the day, they're a business and they exist to make money," said Pickern, who wrote about the negative impacts of prior authorization on patient care for The American Journal of Managed Care.

For most patients, though, the process works seamlessly. Prior authorization mostly happens behind the scenes, almost always electronically, and nearly all requests are quickly, or even instantly, approved.

But the use of prior authorization has also increased in recent years. That's partly due to the growth of enrollment in Medicare Advantage plans, which rely heavily on prior authorization compared with original Medicare. Some health policy experts also point to the passage of the Affordable Care Act in 2010, which prohibited health insurers from denying coverage to patients with preexisting conditions, prompting companies to find other ways to control costs.

"But we can't really prove this," said Kaye Pestaina, director of the Program on Patient and Consumer Protection at KFF, a health information nonprofit that includes KFF Health News. Health insurers haven't been historically transparent about which services require prior authorization, she said, making it difficult to draw comparisons before and after the passage of the Affordable Care Act.

Meanwhile, many states are looking to overhaul the prior authorization process.

In March, Virginia passed a law that will require health insurers to publicly post a list of health care services and codes for which prior authorization is required. A North Carolina bill would require doctors who review patient appeals to have practiced medicine in the same specialty as the patient's provider. The West Virginia Legislature passed bills in both 2019 and 2023 requiring insurers to respond to nonurgent authorization requests within five days and more urgent requests within two days, among other mandates.

And in 2014, the South Carolina Department of Health and Human Services temporarily lifted all prior authorization requirements for Medicaid beneficiaries seeking rehabilitative behavioral health services.

Federal rules to modify prior authorization that were introduced by the first Trump administration and finalized by the Biden administration are set to take effect next year, with the aim of streamlining the process, reducing wait times, and improving transparency.

These changes were supported by AHIP, a trade group that represents health insurers.

'Sick With Little Recourse'

But the new federal rules won't prevent insurance companies from denying payment for doctor-recommended treatment, and they apply only to some categories of health insurance, including Medicare Advantage and Medicaid. Nearly half the U.S. population is covered by employer-sponsored plans, which remain untouched by the new rules.

For some patients, the stakes couldn't be higher.

On May 12, Alexander Schrift, 35, died at home in San Antonio, Florida, less than two months after his insurance company refused to cover the cancer drug ribociclib. It's used to treat breast cancer but has shown promise in treating the same type of brain tumor Schrift was diagnosed with in 2022, according to researchers at the Dana-Farber Cancer Institute in Boston and the Institute of Cancer Research in London.

But Schrift's insurance company refused to pay. The Right to Try Act, signed by President Donald Trump in 2018, entitles patients with terminal illnesses to try experimental drugs, but it does not obligate insurance companies to pay for them.

In May, Sheldon Ekirch, 30, of Henrico, Virginia, said her parents withdrew money from their retirement savings to pay for treatment denied by her health insurance company.

Ekirch, who was diagnosed with small fiber neuropathy in 2023, was recommended by her doctor to try an expensive blood plasma treatment called intravenous immunoglobulin to ease her near-constant pain. In April, a state agency charged with reviewing insurance denials upheld her insurer's decision. Out-of-pocket, the treatment may cost her parents tens of thousands of dollars.

"Never in a million years did I think I'd end up here," Ekirch said, "sick with little recourse."

Earlier this year, New Jersey congressman Jefferson Van Drew, a Republican, introduced a bill that would eliminate prior authorization altogether. But history suggests that would create new problems.

When South Carolina Medicaid lifted prior authorization for rehabilitative behavioral health services in 2014, the department's costs for those services skyrocketed from $300,000 to $2 million per week, creating a $54 million budget shortfall after new providers flooded the market. Some providers were eventually referred to the South Carolina Attorney General's Office for Medicaid fraud investigation. The state Medicaid agency eventually reinstated prior authorization for specific services, spokesperson Jeff Leieritz said.

What happened in South Carolina illustrates a common argument made by insurers: Prior authorization prevents fraud, reduces overspending, and guards against potential harm to patients.

On the other hand, many doctors and patients claim that cost-containment strategies, including prior authorization, do more harm than good.

On Feb. 3, 2024, Jeff Hall of Estero, Florida, became paralyzed from the neck down and spent weeks in a coma after he suddenly developed Guillain-Barré Syndrome. The cause of his illness remains unknown.

Hall, now 51, argued that the Florida Blue health insurance plan he purchased on the federal marketplace hindered his recovery by capping the number of days he was allowed to remain in an acute rehabilitation hospital last year.

Hall said that after he was forced to "step down" to a lower-level nursing facility, his health deteriorated so rapidly within six days that he was sent to the emergency room, placed on a ventilator, and required a second tracheostomy. Hall believes the insurance company's coverage limits set his recovery back by months — and, ironically, cost the insurer more. His wife, Julie, estimated Jeff's medical bills have exceeded $5 million, and most of his care has been covered by his insurer.

"Getting better is not always the goal of an insurance company. It's a business," Jeff Hall said. "They don't care."

In a prepared statement, Florida Blue spokesperson Jose Cano said the company understands "it can be a challenge when a member reaches the limit of their coverage for a specific service or treatment." He encouraged members affected by coverage limits to contact their health care providers to "explore service and treatment options."

A 'Rare and Exceptional' Reversal

Back in West Virginia, Eric and Rebecca Tennant say they are realistic about Eric's prognosis.

They never expected histotripsy to cure his cancer. At best, the procedure could buy him more time and might allow him to take an extended break from chemotherapy. That makes it worth trying, they said.

As a safety instructor with the West Virginia Office of Miners' Health Safety and Training, Eric Tennant is a state employee and is insured by West Virginia's Public Employees Insurance Agency.

As the Tennants pleaded with the state insurance agency to cover histotripsy, they faced a list of other companies involved in the decision, including UMR, a UnitedHealthcare subsidiary that contracts with West Virginia to manage the public employee plans, and MES Peer Review Services, a Massachusetts company that upheld the insurer's decision in March, citing that histotripsy is "unproven in this case and is not medically necessary."

None of their appeals worked. After KFF Health News and NBC News reached out to West Virginia's Public Employees Insurance Agency with questions for this article, the agency changed its mind, explaining the insurer had consulted with medical experts to further evaluate the case.

"This decision reflects a rare and exceptional situation" and does not represent a change in the Public Employees Insurance Agency's overall coverage policies," Director Brent Wolfingbarger said in a prepared statement to KFF Health News.

In a separate prepared statement, UnitedHealthcare spokesperson Eric Hausman said the company sympathizes with "anyone navigating through life-threatening care decisions."

"Currently, there is no evidence that histotripsy is as effective as alternative treatment options available," he said in late May, after the earlier insurance denials were reversed, "and its impact on survival or cancer recurrence is unknown."

MES Peer Review Services did not respond to a request for an interview.

Meanwhile, Rebecca Tennant worries it might be too late. She said her husband was first evaluated for histotripsy in February. But his health has recently taken a turn for the worse. In late May and early June, she said, he spent five days in the hospital after developing heart and lung complications.

Eric Tennant is no longer considered a viable candidate for histotripsy, his wife said, although the Tennants are hopeful that will change if his health improves. Scans scheduled for July will determine whether his cancer has continued to progress. Rebecca Tennant blames her husband's insurance plan for wasting months of their time.

"Time is precious," she said. "They know he has stage 4 cancer, and it's almost like they don't care if he lives or dies."

NBC News health and medical unit producer Jason Kane and correspondent Erin McLaughlin contributed to this report.

Lauren Sausser: lsausser@kff.org, @laurenmsausser

"One out of every $5 or $6 in Medicaid [payments] is improper," said Russell Vought in an interview on CNN’s "State of the Union."

This article was published on Wednesday, June 11, 2025 in KFF Health News.

By Louis Jacobson, PolitiFact 

Responding to charges that President Donald Trump's tax and spending bill would cut Medicaid coverage for millions of Americans, Trump administration officials misleadingly counter that it targets only waste, fraud, and abuse.

During an interview on CNN's "State of the Union," Russell Vought, the administration's director of the Office of Management and Budget, framed Medicaid as sagging under the weight of improper payments.

An "improper" payment refers to payments made erroneously to beneficiaries and their providers or without sufficient documentation.

Pressed June 1 by CNN host Dana Bash about concerns that low-income Americans would suffer if the bill becomes law, Vought called such arguments "totally ridiculous."

"This bill will preserve and protect the programs, the social safety net, but it will make it much more commonsense," Vought said. "Look, one out of every $5 or $6 in Medicaid [payments] is improper."

That would mean Medicaid's improper payment rate is 16% to 20%.

In a 2024 report covering the years 2022, 2023, and 2024, Medicaid's parent agency — the Centers for Medicare & Medicaid Services — said the rate was about 5.1%.

One conservative group, the Paragon Health Institute, said the agency has been using an incomplete calculation method and that the percentage could be as high as 25%. Other experts told PolitiFact that the actual numbers could be higher than what the federal government reports, although not as high as Paragon's estimate.

The White House did not respond to an inquiry for this article.

How High Is the Medicaid Improper Payment Rate?

Medicaid and its closely related Children's Health Insurance program provides health care and long-term care to roughly 83 million lower-income beneficiaries, accounting for about one-fifth of health care spending overall. It is funded through a mix of federal and state money and is administered by states under federal government rules.

Every year, the Centers for Medicare & Medicaid Services publishes official numbers for the share of improper Medicaid payments, and in other federal health insurance programs the agency oversees.

In a 2024 review of payments made in 2022, 2023, and 2024, the agency found that 5.09% of Medicaid payments totaling $31.10 billion were improper.

The 5.09% rate represented a decrease from the 8.58% rate cited in its 2023 report, which was also based on a three-year time span. The 2024 figure represented the third consecutive annual decline.

Are These Numbers Complete?

In March 2025, Brian Blase, a conservative health policy analyst and president of Paragon Health, a health policy think tank, co-authored a report that said the official CMS improper payment rate figures were unrealistically low for eight of the past 10 years, because in some years the agency failed to undergo widespread auditing of its beneficiaries' Medicaid eligibility.

From 2017 to 2019, during Trump's first term, Blase served as Trump's special assistant for economic policy. Before that, he served as a health policy analyst for the Senate Republican Policy Committee and has worked for the Heritage Foundation, a conservative think tank.

The report said if the agency's analysis had looked at eligibility checks every year, more ineligible beneficiaries and payments on their behalf would have been discovered. The report said this might have increased the improper payment rate as high as 25%, based on the rates found in 2020 and 2021, when a high number of eligibility checks were included in the agency's methodology.

However, it's hard to confirm whether lack of eligibility auditing caused higher improper payment rates in 2020 and 2021, said Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities, a liberal think tank.

Wagner said Medicaid enrollment procedures have fluctuated, which could help explain the higher rates in some years rather than others. Using two years of data to generalize about trends across a decade, she said, is not necessarily valid.

Robert Westbrooks, the federal Pandemic Response Accountability Committee executive director who worked in government oversight roles during Democratic and Republican administrations, told PolitiFact it's plausible that the officially reported improper payment rates for Medicaid could be too low.

However, Westbrooks said pinpointing how much higher the rate is in reality is a speculative process. "I don't believe anyone can credibly quantify the [difference]," he said.

What Is an Improper Payment?

Health care experts emphasized that improper payments are not the same thing as waste, fraud, or abuse.

CMS maintains official definitions for these terms:

• Fraud: "When someone knowingly deceives, conceals, or misrepresents to obtain money or property from any health care benefit program."
• Waste: "Overusing services or other practices that directly or indirectly result in unnecessary costs to any health care benefit program. Examples of waste are conducting excessive office visits, prescribing more medications than necessary, and ordering excessive laboratory tests."
• Abuse: "When health care providers or suppliers perform actions that directly or indirectly result in unnecessary costs to any health care benefit program," which can include overbilling or misusing billing codes.

By contrast, an improper payment "includes any payment to an ineligible recipient, any payment for an ineligible good or service, any duplicate payment, any payment for a good or service not received, and any payment that does not account for credit for applicable discounts," KFF, a health information nonprofit that includes KFF Health News, wrote this year.

"Although all fraudulent payments are improper, not all improper payments are fraudulent," said Jessica Tillipman, associate dean for government procurement law at George Washington University's law school. "Most providers identify the improper payments and return them knowing how aggressively enforced" the legal provisions are. "When they don't, they open the door to significant liability."

CMS said about 79% of improper payments happened when there was insufficient documentation.

This typically involved cases in which a state or provider missed an administrative step, and it did not necessarily indicate fraud or abuse, the agency said. Instead, it could be an accidental oversight or mistake.

In other words, it was rare for ordinary beneficiaries to be scamming the government. "The vast majority of fraud in Medicaid is committed by providers or other actors, not enrollees," Wagner said.

Our Ruling

Vought said that "one out of every $5 or $6 in Medicaid [payments] is improper."

The official improper payment rate calculated by the Centers for Medicare & Medicaid Services in 2024 was about 5%, smaller than the 16% to 20% rate Vought described.

A health policy analyst and former Trump adviser said methodological shortcomings in the agency's analysis could mean the rate is as high as 25%. Although it's possible the rate is higher than the 5% the government reported, how much higher is speculative.

The statement contains an element of truth but ignores critical facts, namely the federal government's own data. We rate the statement Mostly False.

Eugene Litvak has been on a mission to save U.S. hospitals money and improve the lives of doctors, nurses, and patients.

This podcast was released on Wednesday, June 4, 2025 in KFF Health News.

By Dan Weissmann

What do the KGB and the former CEO of Cincinnati Children's Hospital have in common?

Eugene Litvak.

The Soviet intelligence agency and the children's hospital have each separately looked to the Ukrainian émigré with a PhD in mathematics for help. He turned down the KGB, but Litvak saved Cincinnati Children's Hospital more than $100 million a year. 

For decades, Litvak has been on a mission to save U.S. hospitals money and improve the lives of doctors, nurses, and patients. He says he has just the formula to do it.

Prominent experts vouch for his model, and he has documented impressive results so far: financial savings, fewer hospital-related deaths, lower staff turnover, and shorter wait times. Still, Litvak and his allies have struggled to persuade more hospitals to try his method.

Host Dan Weissmann speaks with Litvak about his unique life story, how he found the fix that he says could revolutionize American hospitals, and why he won't stop fighting for it.

The monopoly can now be considered a 'clear and convincing' benefit to the public with performance that would earn a 'D' on most A-to-F grading scales.

This article was published on Tuesday, June 3, 2025 in KFF Health News.

By Brett Kelman

Despite years of patient complaints and quality-of-care concerns, Ballad Health — the nation's largest state-sanctioned hospital monopoly — will now be held to a lower standard by the Tennessee government, and state data that holds the monopoly accountable will be kept from the public for two years.

Ballad is the only option for hospital care for most of the approximately 1.1 million people in a 29-county swath of Appalachia. Such a monopoly would normally be prohibited by federal law. But under deals negotiated with Tennessee and Virginia years ago, the monopoly is permitted if both states affirm each year that it is an overall benefit to the public.

However, according to a newly renegotiated agreement between Ballad and Tennessee, the monopoly can now be considered a "clear and convincing" benefit to the public with performance that would earn a "D" on most A-to-F grading scales.

And the monopoly can be allowed to continue even with a score that most would consider an "F."

"It's an extreme disservice to the people of northeast Tennessee and southwest Virginia," said Dani Cook, who has organized protests against Ballad's monopoly for years. "We shouldn't have lowered the bar. We should be raising the bar."

The Ballad monopoly, which encompasses 20 hospitals and straddles the border of Tennessee and Virginia, was created in 2018 after lawmakers in both states, in an effort to prevent hospital closures, waived federal antitrust laws so two rival health systems could merge. Although Ballad has largely succeeded at keeping its hospitals open, staffing shortages and patient complaints have left some residents wary, afraid, or unwilling to seek care at Ballad hospitals, according to an investigation by KFF Health News published last year.

In Tennessee, the Ballad monopoly is regulated through a 10-year Certificate of Public Advantage agreement, or COPA — now in its seventh year — that establishes the state's goals and a scoring rubric for hospital performance. Tennessee Department of Health documents show Ballad has fallen short of about three-fourths of the state's quality-of-care goals over the past four fiscal years. But the monopoly has been allowed to continue, at least in part, because the scoring rubric doesn't prioritize quality of care, according to the documents.

Angie Odom, a county commissioner in Tennessee's Carter County, where leaders have clashed with Ballad, said she has driven her 12-year-old daughter more than 100 miles to Knoxville to avoid surgery at a Ballad hospital.

After years of disappointment in Tennessee's oversight of the monopoly, Odom said she was "not surprised" by Ballad's new grading scale.

"They've made a way that they can fail and still pass," she said.

Virginia regulates Ballad with a different agreement and scoring method, and its reviews generally track about one or two years behind Tennessee's. Both states have found Ballad to be an overall benefit in every year they've released a decision.

Neither Ballad Health nor the Tennessee Department of Health, which has the most direct oversight of the monopoly, answered questions submitted in writing about the renegotiated agreement. In an emailed statement, Molly Luton, a Ballad spokesperson, said the company's quality of care has steadily improved in recent years, and she raised repeated complaints from the hospital system about KFF Health News' reporting. The news organization has reviewed every complaint from Ballad and has never found a correction or clarification to be warranted in the coverage.

Tennessee Health Commissioner Ralph Alvarado, who has more than once described the regulation of Ballad Health as a matter of national importance, has declined or not responded to more than a dozen interview requests from KFF Health News to discuss the monopoly.

"Our effort and progress serve as a model for health care in Tennessee, the Appalachia Region, and the entire nation," Alvarado said in a May news release about the monopoly, adding, "We do not take our role lightly as we remain committed to transparency in our COPA oversight."

Tennessee's revised agreement was negotiated behind closed doors for more than a year and announced to the public in early May. As part of that announcement, Tennessee said it wouldn't score Ballad next year, to give the company time to adjust to the new scoring process.

Under that process, the minimum score Ballad needs to meet to show a "clear and convincing" public benefit has been lowered from 85 out of 100 to 70 out of 100. The new agreement also awards Ballad up to 20 points for providing Tennessee with data and records — for example, a report on patient satisfaction — regardless of the level of performance documented. The state can also raise or lower Ballad's overall score by up to 5 points in light of "reputable information" that is not spelled out in the scoring rubric.

Therefore, Ballad can score as low as 65 out of 100, with nearly a third of that score awarded for merely giving information to the state, and still be found to be a "clear and convincing" benefit to the public, which is the highest finding Tennessee can bestow, according to the agreement. And Ballad could score as low as 55 out of 100 without the monopoly facing a risk of being broken up, according to the new agreement.

The agreement also increases how much of Ballad's annual score is directly attributed to the quality of care provided in its hospitals, from 5% to 32%. But the agreement obscures how this will be measured.

Tennessee sets "baseline" goals for Ballad across dozens of quality-of-care issues — like infection rates and speed of emergency room care — and then tracks whether Ballad meets the goals. The new agreement resets these baselines to values that were not made public, leaving it unclear how much the goals for Ballad have changed. Health department spokesperson Dean Flener said the new baselines would not be disclosed until 2027.

Cook, the longtime leader of protests against Ballad, said she believes Tennessee is attempting to silence data-supported criticism until the final year of the 10-year COPA agreement, which ends in 2028.

By then, any outrage would be largely moot, she said.

"If you are going to wait until the last year to tell us the new measurements, why bother?" Cook said. "It is clear, without a shadow of a doubt, that the Tennessee Department of Health is putting the needs and concerns of a corporation above the health and well-being of people."

Brett Kelman: bkelman@kff.org, @BrettKelman