Senior Vice President
One notice, several teams, and months of rework. Here is how finance leaders can contain the ripple.
Last week, in “The revenue cycle is connected. Accountability should be too,” our president Sid Mehta examined why performance depends on the connections between teams, systems, and partners. I’m diving deeper into how year-end payer changes turn disconnected workflows into repeated work.
As we approach a new plan year, I want finance leaders to follow each payer update beyond the inbox. Revised coverage policies, prior authorization requirements, and documentation standards need to reach every affected team. When a change stops with one team, the cost can follow the organization well into the next year.
For example, let’s say a payer announces in October a documentation change for a common service, effective Jan. 1. One team reads the notice, but the billing workflow team never hears about it. January claims begin coming back denied. By March, staff are preparing appeals while new claims keep entering the same process. Every week the organization treats those denials as separate cases, but the underlying problem remains.
Payer pressure keeps rising while finance carries the cost
KFF’s August 2026 analysis of 2025 data from 14 large insurers found denial rates of 12% to 18% for standard prior authorization requests across Medicare Advantage, Medicaid managed care, and the federally facilitated ACA Marketplace. In Medicare Advantage, 67% of appealed standard denials were overturned. Those appeal findings should reach the teams preparing the next request.
How quickly can your organization recognize a pattern, assemble the evidence, and coordinate the affected teams because some issues call for a workflow correction while others may need a payer conversation or a contract review. Shared evidence helps RCM teams choose the right response.
Fragmentation multiplies the work
In the example, several teams investigated the same payer requirement independently while the original workflow keeps producing claims with the same vulnerability.
Finance leaders should track both the dollars at risk and the cost of recovering them. The American Hospital Association’s 2026 Costs of Caring report estimates hospitals spent $43 billion in 2025 collecting insurer payments for care already delivered!
Underpayments follow the same logic. Teams need to compare a payment variance with the relevant contract terms and check other claims for the same exposure.
How AI can help
AI can shorten the distance between a pattern and a decision. Analytics surface concentrations of denials and payment variances by payer and service. AI groups similar cases for review. Workflow tools route findings to the responsible teams and track the fix. Experts still validate the pattern and choose the response.
I judge technology by how much sooner the organization spots an issue, acts on it, and cuts recurrence. A dashboard should help someone decide what to do next while an “alert” needs someone with the context and authority to act.
Start with one recurring payer problem
Start with your existing systems and partners. I recommend selecting one recurring issue affecting payment and follow it from detection through resolution. Identify the information each team needs and assign one owner for the response.
The review should:
Track revenue at risk
Record time to resolution
Count the share of new claims affected by the same issue
Those three measures help leaders decide where to invest in expertise, workflow changes, or technology.
At Access Healthcare, that’s what we do. We begin with the provider’s current environment and build on the capabilities already working. When a disputed claim teaches the organization something, the next affected claim should benefit. Otherwise, you will pay to learn the same lesson again.
About Access Healthcare
Established in 2011, Access Healthcare remains at the forefront of healthcare management, allowing healthcare organizations to focus on what matters most: their patients. As a global leader, we are recognized as a trusted partner by healthcare organizations, offering a combined AI-embedded, automation, and human expertise revenue cycle management (RCM) operating model to drive visible results at scale.