Michael Hill, MD and Associates, The Claims Dispute Resolution Company
Claims Dispute Resolution Brief
August 19, 2026
Multispecialty Groups · Professional Billing · Denial Recovery

The Appeals Nobody Files

Denial Management for Multispecialty Physician Groups
Federal data has settled the question: denials are rarely appealed, and appeals usually win. If you lead a physician group, that gap is your money, and there is a playbook for closing it.

Ask any physician in your group what wears them down, and it is rarely the medicine. It is the fight over work already done: the visit that was real, the judgment that was right, the payment that never came. And the part that stings most is what happens next: nothing. No one fights. The claim is written off, as if the work never happened.

The numbers say the surrender is almost always premature. In 2024, Medicare Advantage (MA) insurers made 52.8 million prior authorization decisions and said no, in whole or in part, 4.1 million times. Only 11.5% of those NOs were ever appealed. But of the fraction that were, 80.7% were overturned. At some insurers, 95% (KFF, the Kaiser Family Foundation, an independent health policy research organization).

Sit with what that means for your physicians' written-off claims. More likely than not, they would have paid. When someone asked again, the answer usually changed. Nine times out of ten, no one asked.

That silence is not a verdict on the merits; it is an operations story: capacity, deadlines, claims too small to fight one at a time. And it is costing you every month: each unappealed, overturnable denial is your revenue, abandoned, while payors carry rework and, under CMS-0057-F (the Interoperability and Prior Authorization Final Rule), compliance exposure. What follows is the playbook: where denials are born, which ones should never have existed, and how the appeals nobody files become revenue nobody has to chase.

The Verified Numbers Your numbers are not unusual. 41% of providers report denial rates above 10%, and the top triggers are ordinary ones: missing or inaccurate claim data (50%) and authorizations (35%) (Experian Health State of Claims 2025, 250 revenue cycle leaders). Kodiak Solutions' claims data across 2,100+ hospitals puts the average initial denial rate at 11.81% in 2024. And the first disclosures mandated by the 2024 transparency rule from CMS (the Centers for Medicare and Medicaid Services), covering calendar year 2025, show overturn-on-appeal rates of 67% in MA, 47% in Medicaid managed care, and 43% in the Marketplace, while denials remain rarely appealed (KFF).
1

Prevent: The Biggest Leak Is at Intake

Data FirstThe cheapest denial is the one never issued, and most start at the front desk, not the billing office. Run automated eligibility checks (the 270/271 eligibility inquiry and response) twice, at scheduling and again pre-visit, with required-field hard stops so a claim cannot be born broken. When a patient sees two departments in one day, flag it so distinct-service modifiers are documentation-checked, never auto-appended. And track days-to-enrollment by payor: a physician seeing patients before enrollment generates denials with no cure, so hold those charges in a dedicated queue.

The Federal ClockCMS-0057-F sets the timeline: 72-hour expedited and 7-day standard decisions (impacted payers, excluding qualified health plan issuers on the federally facilitated exchanges) plus specific denial reasons from January 1, 2026, and Prior Authorization interfaces built on FHIR (Fast Healthcare Interoperability Resources) from January 1, 2027. One authorization hub with pre-service hard stops and a physician override turns the mandate into a cycle-time advantage.

The Appeals Nobody Files
August 19, 2026
2

Verify: Pre-Bill Discipline on the Claims Payors Target

The ScrubsPayors know exactly which of your claims to test, and the costliest is the office visit billed alongside a procedure. Hold any claim carrying Modifier -25, -59 (or the X{EPSU} set: XE, XP, XS, and XU, the more specific modifiers that replace -59), or -57 until the documentation shows a separately identifiable service; the evaluation and management (E/M) payment at stake runs $100–$400 per visit, repeated across every proceduralist you employ. After surgery, make every same-group visit inside the global period an explicit, auditable choice: Modifier -24, -58, -78, -79, or non-billable post-op care. And for your nurse practitioners and physician assistants, attestation templates should govern incident-to and split/shared billing; when the requirements are not met, the claim automatically reroutes to the advanced practice provider's (APP) own National Provider Identifier (NPI) at 85%. That turns an unmanaged compliance risk into a known, quantified decision.

Measure It HonestlyDo not let one number reassure you. A clean claim rate says your claims passed your own scrubber; a first-pass resolution rate says the payor actually paid. A group can post 96% on the first and 78% on the second, and that gap is precisely the payor-edit exposure this playbook closes. Size pre-bill holds to your auditors' capacity, and coach under-coders as seriously as over-coders; systematic under-coding is pure uncompensated loss.

The Leak The Fix What It Prevents
Registration & eligibility Dual 270/271 checks; required-field hard stops; accuracy scorecards The largest front-end denial category: 22% of all denials (2022 Denials Index, 441M remits)
Same-day multi-specialty encounters Scheduling flags; documentation-checked distinct-service modifiers Duplicate and bundling edits (Claim Adjustment Reason Codes 18, 97) on legitimate care
Modifier -25 / -59 / -57 Pre-bill holds until separately identifiable documentation is confirmed Loss of the E/M component on procedural clinic days
Global package tracking Practice-management-system global-period tracking with forced modifier selection Automated rejection of unrelated care in surgical windows
APP incident-to / split-shared Attestation templates; automatic reroute to the APP NPI at 85% Recoupment and False Claims Act exposure on the 15% differential
Enrollment & credentialing lag Days-to-enrollment tracking; charge holds for unenrolled providers Provider-not-eligible denials with no retroactive cure
Read the Overturn Rate Honestly When your team reports a strong overturn rate, ask one more question. The rate is easily gamed: a team that appeals only its surest cases posts an excellent number while abandoning most recoverable dollars. Ask for it by denial category, administrative overturns approach certainty while clinical validation runs far lower, so a blended rate reflects case mix, not performance. The metric that actually constrains your recovery is the appeal rate: the share of denials your team works at all.
11.5%
MA Denials Appealed, 2024
Of 4.1 million full or partial denials across 52.8M determinations (KFF).
80.7%
Of Those Appeals Won
2024 MA overturn rate on appeal; insurer-level rates ran 51.0% to 95.5% (KFF).
41%
Denials Born at the Front End
2022 Change Healthcare Denials Index: registration/eligibility 22%, authorization 13%.
The Appeals Nobody Files
August 19, 2026
3

Recover: Triage by Deadline, Appeal With Evidence

TriageYour team cannot appeal everything, so make the queue choose well. Feed the 835 electronic remittance advice into a triage engine that sorts every denial by net realizable value, appeal deadline, and root cause, and let deadline proximity, not dollar value alone, drive the work order. Track your denial rate two ways: by claim count for the rework absorbed, and by dollars for the money at risk; the divergence shows where denials concentrate.

EvidenceForm-letter appeals earn form-letter denials. Replace them with clinically grounded briefs built for high-volume, low-dollar claims, citing the American Medical Association's E/M guidelines, ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) Guideline I.A.19, and, for MA, the individualized-review requirement of 42 C.F.R. § 422.101(c)(1)(i). Where a payor systematically upholds improper denials, aggregate the portfolio, present the overturn history at the Joint Operating Committee, and invoke contractual arbitration where warranted.

The federal data has ended the argument over whether the unfiled appeals were worth filing. What remains is an operations question, and operations is the part you control.

Where MHMDAA Comes In

You do not have to build this alone. MHMDAA (Michael Hill, MD and Associates), a revenue cycle consulting and payor-provider dispute resolution firm, brings a dual-perspective methodology built on more than 12,000 disputed-claim reviews, fluent in bedside medicine and managed care adjudication alike. Because it works to the evidentiary standards of expert testimony, its assessments are neutral by design: a finding that would withstand a payor medical director's scrutiny is one you can act on. Engagements span clinical validation audits, competency mapping, and scalable appeal frameworks.

Phase The 6-Month Program
Months 1–2 Revenue cycle management (RCM) diagnostic and payor adjudication audit. 835 remittance analysis, authorization clearance review, and a baseline against the verified benchmarks above.
Months 3–4 Operational redesign. Pre-bill hold slates for high-risk claims; electronic health record templates for medical decision making, incident-to, and split/shared attestation.
Months 5–6 Escalation frameworks and portfolio recovery. Appeal brief templates, Joint Operating Committee preparation, and arbitration readiness.

Based on the gaps typically found between industry-median and best-practice performance, the program is built to a projected 5:1 return on engagement investment, an internal projection, not an industry statistic, validated against your group's own baseline in the first diagnostic phase.

Michael Hill, MD and Associates, The Claims Dispute Resolution Company
Revenue cycle consulting and payor-provider dispute resolution · (877) 464-4556 · Contact us to schedule your RCM diagnostic.
Disclaimer. This brief is educational commentary; it is not legal, coding, or clinical advice, and it is not a determination about any specific claim, payor, provider, or matter. MHMDAA is an independent revenue cycle consulting and payor-provider dispute resolution firm; its principals provide dual-perspective analysis and independent expert services to payors and providers alike, and nothing in this publication constitutes advocacy for either side of any dispute or prejudges any question on which they may serve as independent experts. Authorship. This document was drafted with human authorship and may include AI-assisted formatting or summarization. All analysis, conclusions, and opinions are solely those of Dr. Michael Hill.

Sources