There will come a day when the fax machines fall silent. No prior authorization requests. No “peer-to-peer” calls scheduled at 8:43 a.m. with someone named Chad who last saw a patient during the Obama administration. No algorithm blinking red because a real doctor dared to request rehabilitation for their patient after a stroke.

On that day, physicians across the United States will have agreed, collectively and improbably, to stop working for health insurance companies.

Not to stop caring for patients. Not to stop practicing medicine. Only to stop participating in the elaborate theater known as utilization management, a system in which care is requested, denied, appealed, denied again, and finally approved after the patient has either recovered, deteriorated, or died.

This essay imagines what such a boycott would look like.

It is, of course, satire.

Mostly.

The idea begins with a simple observation: the current system depends on physician labor on both sides of the denial. One physician recommends care. Another physician, often distant, anonymous, and incentivized differently, reviews it and declines.

This dual-physician model creates the illusion of clinical judgment where there may instead be policy enforcement, cost containment, or algorithmic suggestion dressed in a white coat. The result is a peculiar inversion of the profession: physicians arguing against physicians while patients wait for an outcome, trapped in the middle.

Recent reporting has highlighted just how routine these denials have become. In some Medicare Advantage contexts, denial rates for post-acute care are strikingly high, with wide variation among plans and a remarkable pattern: most denials, when appealed, are overturned. In one setting, approximately 95% of appealed denials were reversed, suggesting that the initial decision was less a final judgment than an opening move in a bureaucratic negotiation.

If medicine were practiced this way clinically, we would call it malpractice. Heads, we operate. Tails, we don’t.

Instead, we call it policy. Heads, we deny.

Tails, we deny. Now imagine the boycott.

It would begin, as all revolutions do, with a spreadsheet.

A group of physicians, perhaps primary care, perhaps hospitalists, perhaps those who have spent cumulative years on hold with insurance companies, would circulate a pledge:

“I will not serve in any role that requires me to deny, delay, or obstruct medically recommended care on behalf of an insurer.”

Within weeks, utilization review panels would find themselves understaffed. The “peer” in peer-to-peer would become increasingly theoretical. Calls would be scheduled, but no peers would be available. Denials would still be generated—algorithms are nothing if not tireless—but there would be no one to defend them.

Insurance companies, in response, would innovate.

They would replace physicians with more advanced tools: predictive models, proprietary scoring systems, perhaps even a chatbot with a reassuring name like “CarePath Navigator.” The chatbot would express empathy while denying coverage.

“We understand your patient’s need for rehabilitation,” it might say. “Unfortunately, based on our guidelines, recovery is not currently authorized.”

The difference, of course, is that no physician would be attached to the denial. No one to call. No one to appeal to. No one to share the moral weight.

And that is precisely the point.

The boycott would force a confrontation with a question long deferred: who, exactly, is making medical decisions?

If insurers insist that denials are clinical, then they require clinicians. If they are administrative, then they should be recognized as such and regulated accordingly.

The current system, however, is designed to be ambiguous. Decisions are framed as medical when authority is needed, and as administrative when accountability is requested.

A physician boycott exposes the illusion that utilization review decisions are purely clinical. If physicians refuse to participate as reviewers and deniers, insurers lose the ability to present denials as judgments made by peers.

“Our physician wasn’t making a clinical decision,” goes the company’s party line, “only applying plan benefits.”

The treating physician is told. “You are free to do for your patient whatever you think is best. The UR doctor is not denying care. They’re only denying the benefit.” What remains is unmistakable: an administrative decision with clinical consequences—a company declining to pay, knowing that, for most patients, nonpayment functionally determines whether care can be delivered.

The system is not just a wolf in sheep’s clothing—it is a wolf that insists it is neither wolf nor sheep, but merely a “benefit determination.”

What would happen next is difficult to predict, but easy to satirize.

Congress would hold hearings. Executives would testify. Words like “efficiency,” “value,” and “appropriate utilization” would be deployed with surgical precision.

A senator would ask, “Why are so many denials overturned on appeal?”

An executive would respond, “The appeals process is working as intended.”

This would be technically true in the same way that a fire alarm works as intended when it eventually alerts you after the building has burned down.

Meanwhile, patients and families long accustomed to navigating opaque systems would begin to notice something unusual: decisions were being made without the involvement of physicians.

Some would find this alarming. Others would find it clarifying.

Physicians, for their part, would rediscover a strange and unfamiliar sensation: time.

Time not spent on prior authorizations. Time not spent documenting for an audience of auditors. Time not spent rehearsing the language required to transform a clinical reality into a billable justification.

Freed from these tasks, physicians might do something radical.

They might talk to patients.

They might discuss what’s in the best interest of their patients without consulting a coverage policy. They might recommend care based on need rather than likelihood of approval. They might, in short, practice medicine.

This is where the satire becomes dangerous, because it begins to sound plausible. Of course, a full boycott raises serious concerns.

Patients could be harmed if systems collapse too quickly. Access could worsen before it improves. Physicians themselves depend on reimbursement structures tied to insurers. The system, however flawed, is deeply interdependent.

A boycott is not a solution so much as a stress test, a way of revealing how much of the current structure depends on physician participation in processes that may conflict with their primary obligation to patients.

Historically, physician strikes and boycotts have been rare and ethically fraught, precisely because withdrawal of labor in healthcare carries real risk. The challenge, then, is to distinguish between withdrawing care and withdrawing cooperation with processes that impede care.

The proposal here is the latter.

In the end, the most likely outcome is not a dramatic collapse but a gradual recalibration.

Insurers would be forced to redesign authorization processes that do not rely on physician denials. Transparency requirements might increase. Appeals processes might become less performative and more substantive. Or, perhaps most radically, coverage decisions might be standardized in ways that reduce the need for case-by-case obstruction.

Alternatively, nothing would change.

The system has proven remarkably resilient, absorbing criticism, data, and outrage with equal indifference. Studies may continue to show high denial rates and even higher reversal rates. Physicians may continue to spend hours negotiating for care that is ultimately approved. And patients may go without treatment and continue to suffer until a decision is reached.

But imagine, just for a moment, that the fax machines do fall silent.

Not because medicine has stopped, but because physicians have decided that their role is not to participate in a corrupt system where care is treated as a request to be negotiated rather than a need to be met.

In that moment, the question would no longer be how to appeal a denial.

It would be why the denial existed at all.

And that is a question no algorithm, no policy manual, and no smooth chatbot can answer.

Only people can.

Preferably, the ones actually taking care of patients.