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Issue 12 · August 2026
Four in five appealed Medicare Advantage denials were overturned, and nearly nine in ten denials were never appealed
Before you act on any number here: Practice Insider gives general operational guidance on running an independent practice. It is not legal, compliance, tax, or financial advice. Confirm any prior authorization, appeal, payer contract, enrollment, or Medicare payment step with qualified healthcare counsel, a certified professional coder, or your own advisor before acting on it. Prior authorization, enrollment, and credentialing requirements vary by payer and change frequently, so verify current requirements directly with each payer and with CMS.
The lead: the denials your practice absorbed instead of appealing
The 2025 AMA prior authorization physician survey, a 44 question survey fielded in December 2025 among 1,000 practicing physicians, puts the volume at 40 prior authorizations per physician per week and 13 hours of physician and staff time. Nearly one in three physicians (32 percent) report that requests are often or always denied. Only one in five (21 percent) report that they always appeal an adverse decision. The reason given most often for not appealing, cited by 59 percent, is a belief based on past experience that the appeal will not succeed.
That belief does not survive contact with the Medicare Advantage numbers. Medicare Advantage insurers made 52.8 million prior authorization determinations in 2024 and denied 4.1 million requests in full or in part, which is 7.7 percent of requests. Practices appealed 11.5 percent of those denials. Of the appeals that were filed, 80.7 percent ended in a full or partial overturn.
Read those two figures together. Close to nine in ten denials were never challenged, and four in five of the ones that were challenged got paid. The distance between those numbers is a staffing and workflow decision, made by default, every time a denial gets filed instead of worked.
The federal rule that took effect this year makes the work cheaper to do. Under the CMS Interoperability and Prior Authorization final rule (CMS-0057-F), impacted payers had a January 1, 2026 compliance date for the operational provisions. Impacted payers means Medicare Advantage organizations, state Medicaid and CHIP fee for service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers on the federally facilitated exchanges. Those payers, excluding the exchange issuers, must now send prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests. All of them must give a specific reason for a denial, whatever channel the decision arrives through. None of these provisions apply to prior authorization for drugs.
What to do before the next denial
Start with the payer's own numbers. The same rule requires impacted payers to post prior authorization metrics publicly on their websites every year, with the initial set due by March 31, 2026. Denial rates and turnaround times for the plans you contract with are a published document now, which makes them usable in a contract discussion and usable for deciding which denial categories deserve a standing appeal.
Then measure your own side of it. For one month, log every denial by payer and by service, how many were appealed, and how many were overturned. A practice that appeals almost nothing has no overturn rate of its own to test the current workflow against. If your rate lands anywhere near the Medicare Advantage figure, the staff hour spent on an appeal is among the better paid hours in the building. The specific denial reason a payer now has to provide is the raw material for that appeal, and it is also the fastest way to separate the denials that are documentation fixes from the ones that are coverage disputes worth escalating.
Quick hits
Payments: the card fee on payer money you are allowed to refuse
Some plans pay claims by virtual credit card. Staff keys the card number into the practice terminal, and the interchange fee, commonly around 3 percent and reported as high as 5 percent, comes out of money the payer already owed you. On $1 million of payer receipts, 3 percent is $30,000 a year. CMS states in its HIPAA Administrative Simplification guidance that a health plan cannot require a provider to accept virtual credit card payments, and that a plan must comply if a provider asks to be paid using the HIPAA standard ACH electronic funds transfer. The charge on that transfer is the practice's own bank fee, averaging about 34 cents. Ask each plan in writing to move you to ACH EFT with the electronic remittance advice attached, and file a complaint with CMS if a plan will not do it.
Enrollment: the five year deadline that stops Medicare payment outright
Medicare enrollment has to be revalidated every five years for most providers and suppliers, and every three years for DMEPOS suppliers. Your Medicare Administrative Contractor sends a notice about three to four months before the due date, and CMS posts due dates on the Medicare Revalidation List seven months in advance. Missing the date can put a hold on your reimbursement or deactivate your billing privileges, and Medicare will not reimburse services furnished during the deactivated period. CMS grants no extensions and no exemptions, and reactivation requires submitting a complete enrollment application again. Track every provider's due date yourself rather than waiting on the notice, and revalidate once you are inside three months of it even if nothing has arrived.
Medicare pay: 2.5 of your 2026 points are on loan
The 2026 conversion factor rose 3.77 percent for qualifying participants in advanced alternative payment models and 3.26 percent for every other physician. The components matter more than the totals. A 2.5 percent piece is a temporary increase Congress passed in H.R. 1 for 2026 alone. The permanent statutory piece under MACRA is 0.75 percent for qualifying participants and 0.25 percent for everyone else, plus a 0.49 percent budget neutrality adjustment. Any 2027 budget or multi year contract escalator that carries the 2026 rate forward is carrying 2.5 points that expire unless Congress acts again. A separate change in the same rule redistributes indirect practice expense toward office based work: CMS projects payment for physician services performed in facilities falls about 7 percent overall while payment for services in non-facility settings rises about 4 percent, with steeper swings for specific practices.
Putting this issue to work
Denial and appeal work is the first thing dropped when the billing desk is short staffed, which is exactly how a 10 percent appeal rate happens. If the numbers above describe your practice, the question worth answering before your next renewal is whether denial management belongs in house at all. Compare medical billing and RCM services on GetPracticeHelp and filter by specialty and payer mix.
Compare billing services →On the numbers: prior authorization volume, hours, denial and appeal behavior come from the 2025 AMA prior authorization physician survey (44 questions, 1,000 practicing physicians, fielded December 2025). The Medicare Advantage determination, denial, appeal, and overturn figures are 2024 data as reported by KFF from CMS filings. Rule provisions, compliance dates, and revalidation timelines were read from the CMS fact sheet for CMS-0057-F and the CMS revalidation page. The 2026 conversion factor components come from the AMA summary of the CY 2026 Medicare Physician Fee Schedule final rule. All were checked on August 17, 2026. Survey figures describe physicians in aggregate and payer data describes Medicare Advantage specifically, so your specialty, payer mix, and state will move the specifics. Treat these as anchors to check against your own data, not as guarantees.