APPLIES TO: All plans

For 2026, I had to pick a health plan for my family. When I went to find a good plan that would work for a family of 4, I struggled to really get the details I felt were important to select the best plan. Now, I could compare the basics, but I couldn’t compare the details that decide whether a claim gets paid.

That still bothers me. I’m a physician. I trained in pathology and have focused most of my career on the business side of healthcare. For years, my job was lab stewardship: making sure patients got the right test at the right time. Later, I started my own company, which made me a small business owner who buys health coverage.

First, I started with brokers. A broker is a licensed agent who helps people and businesses choose health plans. Over a few months, I talked with several. Most of their job was to pull up plans on the phone and walk through the differences. They were explaining the basics: deductibles, copays, coinsurance, coverage, and high-level comparisons. More than once, I told them there was one insurer I didn’t want. The conversation kept coming back to that insurer’s plans. With many of the brokers, I came away feeling sold to and pressured.

So my company set up an ICHRA, short for individual coverage health reimbursement arrangement. The company gives each employee a set amount of money, tax-free, to buy their own individual plan. [1] This makes it easier for our employees, who are all remote, to choose plans that fit their family. Therefore, I was able to select a plan through the plan listings that I could make on my own.

I looked at plan after plan from several companies: bronze, gold, gold plus. Every one listed the same basic information to compare plans. The deductible is what you pay before the plan starts paying. The out-of-pocket maximum is the most you pay in a year. Copays and coinsurance are your share of each bill.

Shopping for coverage felt like ordering from a restaurant menu that shows the price and the name of each dish, but not what’s in it. Then, after you order, the kitchen decides whether you can have it or not. With health coverage, that boils down to what I will need to get a prior authorization for or what will happen when a complex illness comes up. Will it be denied? And what are the rules behind the coverage related to medical necessity?

I could look up the drugs we take today, but not the ones we might need next year. There was no way to see which services need prior authorization by plan, which means the plan has to approve them before you get them. There was also no way to see which “medical necessity” rule might be used to deny a claim. Medical necessity is the standard a plan uses to decide whether care is needed enough to pay for. Some insurers post their medical policies online, but those policies are written for doctors and lawyers, aren’t the actual contract, and can change after you enroll. They are sometimes 70+ pages long and not easy to understand.

So I did what most people do. I picked a plan and hoped the denials and prior authorizations wouldn’t stand between my family and the care we need. I hoped the company paying the bill had written a policy I could trust.

I’ve spent more than a decade on the business side of healthcare, and I couldn’t answer these questions. I don’t think most employers or employees can either. That’s why I’m writing this.

Hoping is uncomfortable for a physician. My whole career has been about evidence. We don’t order a test or treatment in the hope that it will be paid for or covered for a patient. We treat patients based on the clinical needs of that disease. Now I had to choose coverage for my own family with nothing to go on but trust.

Medical necessity is a medical question. Deciding whether a patient needs a test or a surgery is what physicians train for years to do. But the rules that decide whether that care gets paid are in insurer policies that, in my experience, often run 70 to 80 pages. Almost no one reads them. Each insurer writes its own, and the rules can differ by plan and by employer. In practice, what I see is that almost no one really knows what’s in their plan.

Physicians do try. We learn the coding rules and work to keep up as they change. It isn’t easy. Learning each payer’s policies, plan by plan, on top of caring for patients, is a lot to ask of anyone. Even the staff who handle claims often learn a new rule when a denial arrives.

Medicare is easier to follow. It publishes its coverage rules in one public database. [2] Commercial insurers post their rules on their own websites, each in its own format, and some rely on outside criteria that don’t have to be made public. [3]

This isn’t a fight between doctors and insurers. Insurers say their prior authorization programs are run under the supervision of medical professionals. [4] Physicians are already inside this system. The question is whether the medical rules behind coverage are clear to the people who have to live with them.

I recently spent a few days at a healthcare conference on payer policy, meaning the rules insurers use to decide what they’ll pay for. We talked about how to make coverage policies clinically relevant and how to simplify prior authorization. One point that was discussed stayed with me: this complexity is expensive for payers too, because they have to hire staff to manage it. It costs everyone. We have to understand how it works before we can fix it.

That’s the work I want to do here. I want physicians in this conversation, explaining it in plain language, before the claim is denied instead of after.

One gap stands out to me. Many people are pushing for transparency on prices. Far fewer are pushing for it on coverage.

Since July 1, 2022, most group health plans and insurers have had to post online the rates they pay doctors and hospitals. That includes self-funded employer plans. [5]

However, coverage is a different story. Since 2026, some plans have had to post prior authorization numbers every year: how often requests are approved and denied, and how long decisions take.

The rule covers these plans:

Employer plans aren’t on the list. [6]

In 1974, Congress passed ERISA, the Employee Retirement Income Security Act. A self-funded plan is one where the employer pays workers’ medical bills from its own money instead of buying insurance. Under ERISA, a self-funded plan isn’t treated as an insurance company, so state insurance laws don’t apply to it. [7] In 2026, 71% of workers with job-based coverage were in self-funded plans. [8]

My working theory is that this leaves most workers in plans where no one has to make the coverage rules clear. My goal is to write about these issues, bring on experts to discuss the root cause of our healthcare system’s structure, and help bring together the experts who can change this for the better.

I don’t think profit is the problem if the public can easily compare what they are getting at the different options. Right now, I don’t believe that it’s possible for the public to truly compare policies and plans and understand what one will give over another. Right now it comes down to the price of the premium. However, if it were easier to truly compare what was going to get covered and not and the quality of care that you received at the level of the members, then my guess would be that there would be a better competitive landscape to even out the profits among companies.

What I think is unfair is that employers often don’t know exactly what they’re buying. Employees don’t know what they’re covered for. And the people who do understand the rules are usually reading them after a claim has already been denied.

Here’s where I’d like this to lead:

Physicians and healthcare leaders: many workers with job-based coverage are in self-funded plans, which state insurance law doesn’t reach. Knowing which kind of plan a patient has tells you which rules apply.

Employers: if your plan is self-funded, you may have more say over its coverage rules.

Ask your HR team or broker: “Is our health plan fully insured or self-funded?” Fully insured means the employer buys a policy from an insurance company. The answer decides which rules your plan follows.

Next week, I’ll go back to the beginning: how health insurance got tied to your job in the first place. After that comes the 1974 law behind most employer plans, and then how medical necessity became the main test for what gets paid.

I’m writing this because I think we can do better, and because I don’t think anyone fixes a system they don’t understand. If you’re a physician, healthcare leader, or employer who has struggled with this, reply and tell me what confused you most. I read every reply.

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. Gavari does not accept money from health insurers or health plans.