Every week, I see patients not because they need to, but because their insurance company says they must. A patient came in recently for one reason only: Her insurer required a referral before she could see a specialist. She didn’t want to. I didn’t need her to. But we both had no choice. After a 20-minute visit neither of us needed, I did what the insurer required: document, click, submit. Days later, the referral was approved. The irony? When I also ordered the MRI that might have made the specialist visit unnecessary, that request was denied. This is the hypocrisy at the heart of American health care. Insurers claim these policies “coordinate care.” In reality, they create dependency on a system built to delay, deflect, and deny.
Referrals were once about quality assurance. In the early HMO era, they helped ensure patients saw the right specialist for the right reason. But in a world of electronic records and team-based medicine, mandatory referrals have become an administrative tollbooth that drains time, money, and trust from both doctors and patients. Insurers say prior authorizations and referral rules reduce unnecessary spending. What they have actually created is a bureaucracy that punishes physicians for practicing evidence-based medicine and punishes patients for following the rules.
I have had patients denied essential medications: insulin regimens, antidepressants, and even treatments for chronic pain. These were not unsafe or unproven therapies. They were simply more expensive than what the insurer preferred. One of my patients tested positive for COVID-19. I prescribed Paxlovid, the standard of care. Her insurer refused to cover it. The out-of-pocket cost was impossible, so she went without. The denial was not medical. It was mathematical. Few moments in medicine feel worse than telling a patient that the care they need is not being denied by me, but by an algorithm.
Even long-established drugs are not spared. A patient recovering from blood clots stopped her medication after learning a 30-day supply would cost more than $600. The system called that a choice. It was not. It was abandonment disguised as efficiency. Another patient, a teacher with diabetes, spent weeks fighting for the only insulin her body could tolerate. By the time approval came, her blood sugars had worsened and her trust in the system had eroded. That trust was never meant for an insurer. It was meant for her physician. Now doctors are caught in a battle we did not create and cannot win alone.
National data confirm what we see every day. Denials are climbing even as insurer profits reach record highs. According to a 2024 Kaiser Family Foundation analysis, nearly one in five prior authorization requests are initially denied, and more than a third of physicians say those delays have caused serious patient harm. The burden of that bureaucracy lands squarely in the exam room. A patient with severe back pain came to see me. I suspected a disc issue and ordered an MRI. The insurer denied it, insisting on six weeks of conservative therapy. Yet if I had referred her to an orthopedist first, the same MRI would likely have been approved immediately. Same patient. Same test. Two visits. Two copays. More cost for everyone. The only difference was time. Six weeks of waiting, six weeks of pain, six weeks of therapy and frustration, only to end up getting the same MRI six weeks later after her condition worsened and her life was put on hold. That is not coordination. It is control.
This is not just inefficiency. It is a moral failure. A system that forces unnecessary visits while denying timely care is not saving money; it is breaking trust.
Insurers defend these barriers with “evidence-based guidelines.” But the evidence they ignore is the patient sitting in front of us, the one who does not fit neatly into an algorithm. Every delayed prescription, every rejected scan, and every unnecessary appointment shifts cost and risk downstream, where it becomes more expensive to fix. We have built a system that measures success in dollars saved, not lives improved.
When primary care physicians recommend a test, a medication, or a specialist visit, it is not about excess. It is about timing, prevention, and context. Yet those judgments are routinely overturned by people who have never met the patient. The fix is not complicated. End redundant referral mandates that add paperwork but no value. Make prior authorizations automatic for evidence-based care. And measure insurers by outcomes and trust, not by dollars withheld.
Saving money by denying appropriate care is not a victory. It is a failure disguised as efficiency.
Every unnecessary referral erodes the relationship the system claims to protect. Patients lose faith. Physicians burn out. Clinics lose hours chasing authorizations that could have been spent healing people. If insurers truly want to control costs, they should start by listening to the clinicians they claim to trust. The cheapest care is not the care that is denied. It is the care that is done right the first time.
When insurers override physicians, they do more than deny care. They erode the bond that holds medicine together. And once that trust is gone, no algorithm, no savings, and no slogan can buy it back.
Ryan Nadelson is chair of the Department of Internal Medicine at Northside Hospital Diagnostic Clinic in Gainesville, Georgia. Raised in a family of gastroenterologists, he chose to forge his own path in internal medicine—drawn by its complexity and the opportunity to care for the whole patient. A respected leader known for his patient-centered approach, Dr. Nadelson is deeply committed to mentoring the next generation of physicians and fostering a culture of clinical excellence and lifelong learning.
He is an established author and frequent contributor to KevinMD, where he writes about physician identity, the emotional challenges of modern practice, and the evolving role of doctors in today’s health care system.
You can connect with him on Doximity and LinkedIn.
