Insurers Regularly Delay, Deny, and Defend Their Treatment Malfeasance

By: Marcus J. Hopkins, Health Policy Lead Consultant, ADAP Advocacy

New research conducted by Johns Hopkins Bloomberg School of Public Health and published in the Journal of the American Medical Association Health Forum found that health insurance denials for brand-name medications increased by 67% between 2018 and 2024, from 24.3% in 2018 to 40.7% in 2024 (Wang et al., 2026). It is yet the latest news showcasing how insurance companies are putting the squeeze on patients.

Photo Source: Johns Hopkins

Wang et al. utilized 2024 IQVIA pharmacy claims data to identify branded drug dispensations that faced initial prior authorization (PA) rejections and completed the PA process, calculating the frequency of same-day PA reviews and final approval rates.

They found that nearly one-third of initial prescription fill attempts (32%) were rejected because of formulary exclusions, including the medication not being covered by the patients’ insurance plan or because of utilization management rules (PA requirements). Of those rejections, nearly half (48.4%) were not followed by a prescription fill of either the prescribed drug or a drug in the same therapeutic class within 90 days. Those patients who were able to successfully appeal their rejections waited an average of 12 days before receiving their prescriptions (Bloomberg School of Public Health, 2026).

These findings highlight a common strategy employed by health insurance companies in the United States: “Delay, Deny, Defend.” This strategy—also the title of a 2010 book about the insurance industry written by Jay Feinman—is implemented by insurers in order to increase profits. Here’s how it works:

Insurers “delay” the processing of claims—particularly PA claims—in order to frustrate policyholders into abandoning their claims. This is accomplished by introducing bureaucratic obstacles, such as requiring numerous forms or claiming that forms were incorrectly filled out or filed, in the hopes that, by increasing the number and length of delays, insured patients will abandon their treatments.

Insurers also “deny” insurance claims, even if services are listed as being covered by a patient’s explanation of benefits. They utilize this tactic knowing that a vanishingly small percentage of patients will appeal those denials. Data published by KFF in March 2026 found that, among marketplace insurance plan holders, fewer than 1% of denied claims were appealed by policyholders. When policyholders do appeal, two-thirds of those appeals are rejected (Long et al., 2026).

If neither the “delay” nor “deny” tactics are successful, insurers may choose to “defend” their decisions in court. These legal battles can be extensive, last for years, and be both financially and emotionally taxing, which insurers rely upon to dissuade patients from fighting back against them (DeShaw, 2024).

Photo Source: Wikipedia

Wang et al.’s research found significant disparities between payors. Marketplace exchange plans and Medicaid managed care plans had the highest rates of denials—the plans most likely to be utilized by patients who have lower incomes or chronic ailments—with nearly half of all initial prescription attempts denied. Meanwhile, Medicare plans had lower rejection rates. Rejection rates may be lower because the vast majority of prescription drug prices are not negotiable under Medicare plans, while price negotiations are legal for commercial and Medicaid plans, meaning higher profits and payouts under Medicare plans.

As with last week’s blog ("Co-Pay Accumulators Are a Craven Attempt to Accumulate Profit Off the Backs of Patients"), this fundamental truth must be recognized and accepted to understand why these tactics are used:

The purpose of commercial health insurance companies is not to provide access to healthcare services; it is to make profits.

So long as the profit motive exists, insurers will work to ensure that they make those profits, even if it means that patients delay or abandon treatment; even if it means that patients die.

These strategies underpin another looming threat:

State programs, including those in Colorado and Connecticut, have recently been moving HIV antiretroviral medications out of protected drug classes that are generally covered under Medicaid medical benefits, and onto prescription drug formularies, creating lists of approved HIV therapies.

Photo Source: WalletInvestor.com

This poses a significant threat to people living with HIV/AIDS, as virtually every medication used to treat HIV is a brand-name drug. By removing HIV treatments as a medical benefit and placing them into a prescription benefit, patients whose HIV can only be managed by specific drug classes due to drug resistance may face the real risks that their prescriptions may be denied not because those drugs are not effective, but because payors wish to reduce prescription drug expenditures and make profits.

ADAP Advocacy vehemently opposes efforts by states and commercial insurers to profit off of patients. We need legislation that ends these practices. Whether politicians have the political will to enact such policies has yet to be seen.

Disclaimer: All funders of the ADAP Advocacy Association are publicly listed on our website. 

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association; rather, they provide a neutral platform for the author to promote open, honest discussion of public health-related issues and updates.

References:

[1] Bloomberg School of Public Health. (2026, July 10). Insurance Denials for Brand-Name Prescription Drugs Rose Sharply From 2018 to 2024. Baltimore, MD: Johns Hopkins University: Bloomberg School of Public Health. https://publichealth.jhu.edu/2026/insurance-denials-for-brand-name-prescription-drugs-rose-sharply-from-2018-to-2024

[2] DeShaw, A. (2024, December 11). What Does “Delay, Deny, Defend” Mean? Portland, OR: DeShaw Law: Blog. https://www.deshawlaw.com/blog/what-does-delay-deny-defend-mean

[3] Long, M., Lo, J., & Pestaina, K. (2026, March 24). Claims Denials and Appeals in ACA Marketplace Plans in 2024. San Francisco, CA: KFF: Topics: Patient and Consumer Protections. https://www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/

[4] Wang, Y., Levy, J. F., Mattingly, T. J., II, & Anderson, G. (2026, April 17). JAMA Health Forum, 7(4), e260760. https://doi.org/10.1001/jamahealthforum.2026.0760