**2.1 Growth of a denial industry**

"Denial management" became a growth industry of its own aimed at denying physicians' and hospitals' claims for services provided [5]. Many insurers developed ways of avoiding coverage of higher risk people in the first place. One such technique was to hold marketing meetings on the second floor of buildings without elevators to discourage less mobile and older people. Another technique was to make steep increases in premiums after receiving claims from enrollees who were sicker than expected. Denial of claims through burdensome pre-authorization of service became still another way to avoid paying expensive claims, increasingly associated with ever-changing networks. Out-of-network claims for hospital and physicians' services became unaffordable for many enrollees; even for in-network claims, the average denial rate today is 18% [6].
