Healthcare providers are being asked to do more than ever simply to get paid for services they have already provided. Automated claim edits. Downcoding. Requests for medical records. Prior authorization. Prepayment review. Online claim investigations. Reconsiderations. Appeals. Coding validation. Provider portals. Reprocessing requests. For medical practices, getting a clean claim out the door is increasingly only the beginning.
At Comprehensive Physician Consulting (CPC), we see this every day. A claim can be coded correctly, submitted timely, and supported by documentation — and still requires additional work before appropriate reimbursement is received.
The Growth of Automated Claim Review and Downcoding
One of the most significant developments in revenue cycle management is the increasing use of automated and data-driven claim review processes. Cigna’s Evaluation and Management Coding Accuracy policy provides for review of professional claims billed with certain higher-level E/M codes, including 99204–99205, 99214–99215, and 99244–99245. Cigna states that services may be adjusted by one level when its criteria determine the reported level does not meet applicable E/M guidelines. Aetna also has an Evaluation and Management Claim and Code Review Program. Aetna states that its contracted vendor evaluates certain Level 4 and Level 5 E/M services using information including the billed claim and member and provider claim history.
Medical organizations have raised concerns about these programs because an E/M claim can potentially be paid — but at a lower level than the provider originally submitted.
That creates another responsibility for medical practices and their billing companies:
It is no longer enough to determine whether a claim was paid. Practices must determine whether it was paid correctly.
Statistics Show How Significant the Administrative Burden Has Become
The American Medical Association’s 2026 reporting on its physician prior-authorization survey illustrates the scope of the problem:
- 74% of physicians reported that prior-authorization denials had increased during the previous five years.
- 32% said prior-authorization requests were often or always denied.
- Physicians and their staff spend an average of 13 hours per physician every week completing prior authorizations.
- 40% of physicians employed staff dedicated exclusively to prior authorization.
- Physicians reported completing an average of approximately 40 prior authorizations per week.
The increasing role of artificial intelligence and automated decision-making has also generated concern. In a 2025 AMA survey, 61% of physicians said they were concerned that health plans’ use of AI was increasing prior-authorization denials.
Regardless of whether an individual denial results from automation, claim-editing logic, documentation requirements, payer policy, or human review, the practical consequence for the provider is often the same:
More administrative work is required to get the claim resolved.
Government Audits Have Also Identified Incorrect Denials
This is not simply anecdotal frustration from physician practices. The U.S. Department of Health and Human Services Office of Inspector General reviewed Medicare Advantage denials and found that 13% of denied prior-authorization requests in its sample met Medicare coverage rules. The OIG also found that 18% of denied payment requests met both Medicare coverage rules and the Medicare Advantage organization’s billing rules. The OIG identified human error and claims-processing system errors among the causes of some payment denials. Importantly, some incorrect denials were ultimately reversed after providers or beneficiaries disputed or appealed them. More recent federal findings make the importance of follow-up even clearer.
In a 2026 review involving Medicare Advantage skilled nursing facility admission requests, the OIG reported that beneficiaries and providers appealed only 18% of SNF denials.
But when they did appeal:
95% of the appealed denials were overturned in favor of the enrollee.
For denials issued by the contractor naviHealth in the study, 97% of appealed SNF denials were overturned. Those numbers illustrate an important lesson for healthcare providers:
The initial payer decision is not necessarily the final answer.
At the Same Time, Payers Are Moving Providers Toward Portals and Self-Service
Another major change CPC has observed is the continued migration of payer communications toward online portals, electronic investigations, automated systems, and self-service tools.
Independence Blue Cross provides a good example. IBX instructs participating providers to use its PEAR Practice Management system to check claim status. Once a claim is finalized, providers can submit a claim investigation electronically.
IBX’s published guidance has specifically encouraged providers to use this process to track claims rather than immediately calling. Under the published workflow, a provider may have to wait until a claim is finalized before opening an investigation, submit the investigation electronically, and then allow additional time for a response.
Online tools are useful, and CPC uses payer portals extensively.
But there is an important distinction:
Submitting an online inquiry is not the same thing as resolving an account receivable problem.
- A portal can tell us that a claim was processed.
- It can tell us that an investigation was submitted.
- It can provide a reference number.
- It can tell us that an investigation was closed.
- What we ultimately needs to know is:
Was the provider paid correctly? If the answer is no, our work is not finished.
This Is Where CPC Billing Is Different
There is a significant difference between simply processing medical claims and actively managing a physician’s revenue cycle.
At Comprehensive Physician Consulting, we believe a billing company’s responsibility does not end when a claim is transmitted or when an electronic inquiry is submitted.
We work the claim.
Depending upon the payer and circumstances, CPC may:
- Review the EOB, ERA, denial, adjustment, or downcoding reason.
- Review coding, modifiers, authorization, eligibility, and other claim information.
- Compare the payment received with the expected reimbursement.
- Submit medical records and supporting documentation when required.
- File reconsiderations and formal appeals.
- Prepare detailed, individualized appeal letters when a written clinical or reimbursement argument is necessary.
- Follow electronic payer investigations.
- Contact Provider Services when telephone follow-up is available and appropriate.
- Escalate unresolved matters to Provider Relations, Network Management, credentialing departments, or other payer representatives when warranted.
- Obtain and document reference numbers and payer instructions.
- Request claim reprocessing when a representative identifies a processing problem.
- Follow the account after reprocessing is requested to make sure the correction actually occurs.
- Continue pursuing an unresolved balance rather than assuming the payer’s first response is necessarily the final answer.
We take the same hands-on approach to credentialing. Seeing the word “pending” in a credentialing portal does not tell us why an application is pending, whether information is missing, whether the provider has been loaded correctly, or whether intervention with the payer is necessary.
- Sometimes someone has to investigate.
- Sometimes someone has to escalate.
- And sometimes someone simply has to pick up the telephone.
Sometimes the Phone Call Makes the Difference
CPC has repeatedly encountered situations in which a claim remained denied or incorrectly processed until we spoke directly with a payer representative. We have had representatives review the account while we were on the telephone, recognize the issue, and submit the claim for reprocessing.
That human interaction matters. Not every payer issue can be resolved by telephone, and increasingly some insurers require certain matters to proceed through portals, written reconsiderations, medical-record submissions, or formal appeal processes.
The key is knowing which avenue to use, when to escalate, and when the first response warrants further investigation.
An experienced billing company should know the difference between:
“The payer responded”
and
“The problem was resolved.”
Those are not always the same thing.
Why the Billing Company You Choose Matters
Technology and automation have an important place in medical billing. CPC uses electronic claims, payer portals, automated eligibility systems, electronic remittance information, claim-scrubbing technology, and other tools every day. But automation cannot replace every part of revenue cycle management. When an insurer downcodes an E/M service, requests records, denies a procedure, processes a claim incorrectly, requests additional credentialing information, or requires a formal appeal, someone still needs to determine what happened and decide what to do next. That distinction is particularly important when comparing a hands-on revenue cycle partner with a high-volume billing model — whether domestic or overseas — that may rely primarily on standardized workflows, electronic status checks, or scripted follow-up.
The issue is not where the billing staff is located.
The issue is how the account is worked.
CPC’s approach is individualized. We know our clients, their specialties, their payer contracts, their recurring reimbursement issues, and their credentialing history.
- When a situation requires a telephone call, we make the call.
- When it requires records, we submit the records.
- When it requires an appeal, we prepare the appeal.
- When it requires escalation, we pursue the appropriate payer contact.
And when a payer says a claim will be reprocessed, we do not consider the account resolved simply because we received a reference number. We follow it to determine whether the appropriate reimbursement was actually received.
A Denial Is Not Always the End of the Claim
The federal government’s own findings demonstrate why persistence matters. When 95% of appealed Medicare Advantage SNF prior-authorization denials in a 2026 OIG review were ultimately overturned, it raises an important question for every medical practice:
What happens to the claims and authorizations that nobody takes the time to challenge?
Revenue cycle management is no longer simply about submitting clean claims.
It is about understanding payer rules, monitoring reimbursement, identifying underpayments and downcoding, responding to documentation requests, navigating portals, communicating with payer representatives, writing effective appeals, escalating unresolved problems, and continuing to follow the account until there is an appropriate resolution.
At Comprehensive Physician Consulting, that is what we mean when we say we manage the revenue cycle.
We submit the claim. We review the payment. We identify the problem. We follow up. We call when calling is available and warranted. We appeal when an appeal is necessary. And we continue working the account.
Because getting the claim submitted is only part of the job.
Getting the provider appropriately paid is the goal.
References
American Medical Association. AMA Survey: Prior Authorization Reform Pledge Falls Short with Physicians. 2026. https://www.ama-assn.org/press-center/ama-press-releases/ama-survey-prior-authorization-reform-pledge-falls-short-physicians
American Medical Association. How AI Is Leading to More Prior Authorization Denials. March 10, 2025. https://www.ama-assn.org/practice-management/prior-authorization/how-ai-leading-more-prior-authorization-denials
U.S. Department of Health and Human Services, Office of Inspector General. Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care. April 2022. https://www.oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/
U.S. Department of Health and Human Services, Office of Inspector General. Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials. 2026. https://www.oig.hhs.gov/reports/all/2026/medicare-advantage-organizations-overturned-nearly-all-appealed-prior-authorization-denials-for-skilled-nursing-facility-admission-raising-concerns-about-initial-denials/
Cigna Healthcare. Evaluation and Management Coding Accuracy (R49). Provider Newsroom, 2025 Clinical, Reimbursement and Administrative Policy Updates. https://providernewsroom.com/cigna-healthcare/2025-clinical-reimbursement-and-administrative-policy-updates/
Aetna. Evaluation and Management (E&M) Program Claim and Code Review.https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/ny-em-code-claim-review.pdf
Independence Blue Cross. Avoid Calling: Take These Steps to Track Claim Status. Provider Communications. https://provcomm.ibx.com/archive-ibc/news/Pages/22-3323.aspx
Independence Blue Cross. Provider Contact Information and PEAR Portal Resources.https://www.ibx.com/resources/for-providers/contact-us/index.html
