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I’m Heather Signorelli, a physician who has spent more than a decade on the business side of healthcare. Gavari explains how health coverage really works, so we can fix it.

This fall I sat down to choose a health plan for my family. I found the premium in a few seconds. I found the deductible, the copays, and the out-of-pocket maximum. What I couldn’t find was the part that decides whether the care my family might need would actually be paid for: which tests and procedures need approval first, what the plan considers medically necessary, and whether the doctors listed in the network were really taking new patients.

I have spent my career on the business side of healthcare, and I still couldn’t see it. As you can imagine, most people picking a plan this fall can’t either. And we are all paying more every year for that blind spot. In 2026, the average family plan through an employer costs $28,303, and workers pay $7,471 of that themselves, up 9% from last year. [1]

The parts of a health plan you can compare are the parts about price: the premium, the deductible, the copays, and the most you’ll pay in a year. Since 2012, every plan has also had to give you a standard plan summary, which I wrote about in an earlier issue. [2] It lists the basic categories of care and what you’ll pay for each.

For those of you new to this space, that summary was meant to make plans easy to compare. It does that for prices. It doesn’t do it for the rules.

The rules that decide whether a claim gets paid live somewhere else, and most of them are hard or impossible to find before you sign up. Even if you can get to the policy documents, in my experience they are often 70+ pages long and full of difficult medical and legal jargon. The details we need to understand what coverage means are not always visible.

So essentially, you can compare what a plan costs. You can’t compare what it will actually pay for.

This isn’t rare. In a 2023 KFF survey, 58% of insured adults said they had a problem using their insurance in the past year, such as denied claims, network problems, or prior authorization. About half had trouble understanding at least one part of their coverage, and 36% said they didn’t understand what their insurance would cover. Among those who had problems, 17% said they couldn’t get the care their doctor recommended. [6]

Denials are common too. Insurers selling plans on HealthCare.gov denied 19% of in-network claims in 2023, and fewer than 1% of denied claims were appealed. [7] In Medicare Advantage, about one in eight prior authorization requests were denied in 2025, and when people did appeal, two out of three denials were reversed. [8]

What worries me most as a physician is how often the denial is for care that follows the evidence. In the American Medical Association’s most recent survey, conducted in December 2025, about 31% of physicians said the criteria plans use for prior authorization are rarely or never evidence-based. [9] What we don’t know is how many individual denials that adds up to, because plans don’t report it. However, it tells me that the rules physicians are working against are often not the same rules they learned in training and follow in practice.

A patient chooses a plan by premium and by which doctors are listed. Months later, the physician orders the test that the evidence calls for. The front desk or billing staff send the prior auth request, and it comes back denied under criteria nobody in the office can see. The patient thought they were covered. The practice either spends hours on an appeal or the patient goes without. None of that was visible on the day the patient picked the plan.

I also want to be fair here. Insurers say prior authorization and medical necessity reviews protect patients from tests and procedures they don’t need, and help keep premiums from rising even faster. KFF also found that since 2021, family premiums rose 28%, about the same as wages, which rose 27%. [1] And most people still like their coverage. In the same 2023 survey, 81% of insured adults rated their insurance good or excellent. [6] So this isn’t a story about plans that do nothing. It’s about plans you can’t fully see before you buy them.

What this tells me is that we’re asking people to buy the most important financial protection they have while only showing them the price. If every plan had to publish its prior authorization list, its medical necessity criteria, and its denial and appeal rates before enrollment, people could compare plans on what actually matters, and plans could compete on how well they cover care instead of only on price.

We also need a basic set of coverage that every plan on the market has to include, so at least you know you will get what you need if something serious happens. The ACA started this for individual and small-group plans, which have to cover ten categories of “essential health benefits,” like hospital care, maternity care, and prescriptions. Large employer and self-funded plans don’t have to. [2] And even where those categories are required, each plan still decides which specific care inside them needs approval and what counts as medically necessary. So a true basic standard would need both: the care every plan covers, and clear rules for how that care gets approved. Then the premiums across “basic” plans could be compared evenly, and the competition would be based on denial and appeal rates and quality for their members.

I don’t think we need to wait for Washington to start. Employers, physicians, and patients can ask for this information now.

Physicians and practice leaders: when patients ask which plan to pick, point them to three things to request before enrolling: the plan summary, the prior authorization list, and the full plan document. Track denials for care that follows the guidelines, and appeal them. Most are never appealed, and many that are get reversed. [8]

Employers: before your next renewal, ask your plan or broker for the prior authorization list, the source of the medical necessity criteria, and the plan’s denial and appeal rates. If they can’t provide them, that tells you something.

“Before I sign up, can you show me which services need prior authorization, and the criteria you use to approve them?”

Next, I want to follow the money behind that $28,303, including the parts you never see on your paycheck.

Help more people see how this works. If this issue helped you, forward it to one colleague, practice leader, or employer who should read it. If someone forwarded it to you, you can subscribe free at gavari.co.

And if you have a story about a denial, a delay, or a coverage rule nobody could explain, reply and tell me. Please leave out names and anything that could identify a patient.

Gavari does not take money from health insurers or health plans. If an issue has a sponsor, it is labeled at the top.

This is general education about how health coverage works. It is not insurance, legal, or medical advice. I do not sell insurance or recommend plans.

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