Payers Are Stalling — Here’s How to Push Back

If you’ve noticed insurance payments dragging longer than ever, you’re not imagining things. In 2024, payers have become pros at the slow roll — delaying claims, burying providers in red tape, and quietly boosting their bottom line while your revenue suffers. Whether it’s AI-triggered denials, endless prior auths, or radio silence on high-dollar claims, providers are being squeezed harder than ever. The result? Lost revenue, strained staff, and a whole lot of unnecessary chaos. But the good news is: there are ways to fight back — and win.

Let’s start with the numbers. Initial denial rates are climbing across the board — now hovering around 11.8% — and commercial plans are a key contributor. Medicare Advantage plans have seen denial rates spike by more than 4.8% in the past year alone. UnitedHealthcare, Cigna, and others are increasingly using AI to flag and stall high-dollar claims, particularly those over $10,000. If a claim looks “suspicious” or just expensive, it’s likely headed straight to the delay pile.

Another weapon in the payer delay playbook? Prior authorizations. More than 20% of all claims now require one, and in Medicare Advantage specifically, the number of services requiring prior auth has grown from 25% to over 30%. It’s a deliberate bottleneck. These roadblocks are costing providers — not just in time, but in real money. In 2023 alone, the industry spent over $25.7 billion on claims adjudication, with nearly $18 billion of that being classified as avoidable overhead tied to denials and rework. Appealing a single denial now costs providers anywhere from $43 to $64, depending on the payer, and yet nearly 62% of appealed prior auth denials are ultimately overturned. Translation? These aren’t legitimate denials — they’re stall tactics.

The financial impact on practices is staggering. Providers are waiting an average of 47 days for payment, and nearly one-third of them are stuck waiting on balances over $100,000. Blue Cross Blue Shield plans, in particular, are responsible for about 23% of these large delayed amounts. At the same time, hospitals and practices are watching their cash reserves dwindle — the average hospital now holds just 197 days of cash on hand, the lowest in over a decade.

Let’s name names. UnitedHealth has introduced aggressive AI-driven denial systems through Change Healthcare, and during the company’s high-profile ransomware outage, payment delays hit an estimated $100 million per day. Cigna is also leveraging AI to target big-ticket claims, especially in specialties like orthopedics and cardiology. Meanwhile, Blue Cross plans consistently rank among the worst in terms of unpaid balances over 90 days. These aren't isolated incidents — they reflect an industry-wide trend of using technology not to improve efficiency but to drag out payment and reduce disbursement.

So, what can you do about it? Fighting back against payer delays starts with visibility. The most effective revenue teams create internal dashboards that track payer-specific metrics like average days to pay, denial rates by category, appeals success rate, and the percentage of AR over 60 or 90 days. Reviewing this data weekly helps practices identify which payers are consistently underperforming and provides leverage when escalating unpaid claims. Data-backed conversations with payer reps are far more productive than emotional ones — and these patterns can also shape how you prioritize appeals. Every major payer should have a clear escalation process mapped out. Assign a primary contact for each payer and build out an internal chain of escalation, ideally moving from account rep to supervisor to regional escalation team or medical director. It’s also smart to prepare payer-specific appeal templates and complaint letters. If a clean claim hasn’t been paid after 30 days, don’t wait — escalate immediately. And when you escalate, make sure you reference any applicable state “prompt pay” laws to remind payers of their legal obligations.

Prior authorization delays are a major contributor to payment stalls, so automating and monitoring the PA process is critical. Use tools like Availity, ZirMed, or even integrated PM/EHR systems to flag procedures that regularly trigger PA issues. High-risk services like imaging, outpatient surgery, and certain DME items should be reviewed carefully. Build out payer-specific checklists with pre-loaded medical necessity requirements so that your front desk or intake teams can submit PA requests early. If a denial comes in, escalate to peer review right away — waiting only drags things out further.

One of the biggest mistakes practices make is resubmitting denied claims with little more than a sticky note. That won’t cut it. Effective appeal letters cite the payer’s own policy language, reference detailed clinical documentation, and explain the financial impact to both the patient and the provider. For recurring payer issues, attach a copy of a complaint filed with your state’s Department of Insurance or CMS. The goal is to demonstrate that you understand the rules and that you’re documenting their violations.

Don’t overlook your legal leverage. Many states require payers to reimburse clean claims within 30 or 45 days. If they don’t, and there’s no valid denial reason, you are within your rights to file a formal complaint. Doing so not only initiates an external review but can also prompt faster resolution on future claims. For Medicare Advantage plans, you can escalate directly to CMS — and the mention of that is often enough to get results.

Tracking denial overturn rates by payer is another critical tool in your strategy. If your team finds that Cigna overturns 60–70% of appealed denials, it’s worth investing effort in those cases. On the other hand, if Aetna rarely reverses anything, deprioritize low-dollar claims from them and focus elsewhere. Keep a running log of your appeals outcomes and denial categories, then review it quarterly with your team and your providers. These insights can also help during contract negotiations or when escalating patterns to national organizations like AMA or MGMA.

On the clinical side, it’s essential to loop your providers into the conversation. Many delays originate from documentation issues, especially with high-risk codes like E/M visits billed with modifier 25, procedures involving implants, and time-based telehealth visits. Regular internal audits of denied claims — even a small weekly sample — can help identify patterns. Use those findings to train providers on where documentation is falling short, and provide templates or checklists that make compliance easier.

Finally, remember that you’re not alone in this fight. Local billing co-ops, MGMA chapters, and specialty organizations often host payer workgroups where providers share issues and successes. If one doesn’t exist in your area, start one. Collective pressure — especially when paired with data and documented payer behavior — can be a powerful tool. Practices that band together are better positioned to submit coordinated complaints, identify abusive trends, and demand accountability. And if all else fails? Take it public. Practices are increasingly using platforms like LinkedIn or industry publications to shine a light on chronic payer issues. This kind of exposure may feel uncomfortable, but payers are far more responsive when their brand reputation is on the line. It’s not about being dramatic — it’s about being visible, strategic, and impossible to ignore.

The bottom line is this: payers are counting on providers to stay too overwhelmed, too under-resourced, and too used to the chaos to push back. Prove them wrong. Build

better systems, track the delays, and escalate strategically. They may be stalling, but you don’t have to. Sloan Medical July 22, 2025