RCM Leaders Flag Payer Behaviors and Claims Denials as Top Risk for 2026

A new survey of revenue cycle management leaders reveals that payer behaviors and claims denials — not staffing shortages, technology gaps, or regulatory complexity — are the single biggest threat to revenue growth heading into 2026. The reimbursement environment is the problem. And it's getting harder to work around.

What the Survey Says

According to recent reporting from Fierce Healthcare, RCM executives across health systems, physician groups, and specialty practices ranked the reimbursement environment as their primary growth constraint for the year ahead. Specifically, payer behaviors — aggressive prior authorization requirements, escalating denial rates, and slow adjudication — are creating sustained drag on collections that most organizations haven't found a structural fix for.

This isn't a new complaint. But what's notable is that it's now outranking every other operational challenge. Organizations have largely figured out how to staff around the shortage. They've adapted to EHR changes. The payer problem, though, keeps compounding — and the data shows that RCM leaders know it.

Why Payer Behavior Is Getting Harder to Manage

There are three dynamics converging in 2026 that explain the elevated concern:

1. Prior authorization requirements keep expanding

MA plans and commercial payors have steadily broadened the list of procedures requiring prior auth over the past three years. CMS data shows prior auth denial rates in Medicare Advantage running 2-3x higher than in traditional Medicare. What used to require auth for surgery now extends to imaging, durable equipment, and in some cases, routine outpatient procedures. Each new requirement adds workflow cost and creates a new denial vector.

2. Denial complexity is increasing

Payors are no longer just denying on simple eligibility or authorization grounds. Denials increasingly cite medical necessity, coding specificity, and clinical documentation gaps — all of which require clinical expertise to appeal, not just billing staff. The average cost to work a denial has gone up substantially, and overturn rates on first-level appeals have declined across most specialty lines.

3. AI is now on the other side of the table

Major commercial payors have deployed AI-assisted claim review tools that identify denial opportunities at the point of adjudication. That means the speed and precision of payer-side denial generation has increased significantly — while most provider-side RCM teams are still operating with manual workflows and reactive follow-up queues. The gap is real and it's widening.

What High-Performing RCM Teams Are Doing Differently

The organizations that are managing this environment successfully share a few common characteristics:

• They're tracking denial root causes at the code level — not just denial rate as a summary metric. Knowing your top 10 denial reason codes by payor and procedure gives you an actual action plan. Knowing your overall denial rate gives you a number to report.
• They've mapped their payor contract landscape — including network participation, leased arrangements, and where repricing happens. Silent PPO leakage and underpayment from network stacking is a separate problem from denials, but it compounds the revenue loss.
• They're using payor policy intelligence proactively — not just reacting to denials after they happen. If a payor updates its prior auth policy for a procedure category you bill heavily, you want to know before the first denial hits, not after.
• They've closed the loop between billing and clinical documentation — particularly for medical necessity denials. Clean claims start upstream. If your documentation doesn't support the level of service billed, no amount of appeals work will fix it.

The Technology Gap Is Real

It's worth being direct about where most practices stand: the tools available to RCM teams have not kept pace with what payors are now deploying. That doesn't mean the situation is hopeless — it means the organizations that close that gap first will have a structural advantage in collections for years.

The specific gaps that matter most right now:

• Real-time payor policy lookup — most teams are still relying on manual portal searches or outdated internal guides
• Denial prediction at the claim level — flagging high-risk claims before submission rather than after adjudication
• Network path visibility — knowing which umbrella network reprices a claim and what fee schedule applies

These aren't futuristic capabilities. They exist today. The barrier is usually awareness and integration, not technology availability.

What to Watch in Q2

A few specific developments worth monitoring for RCM teams over the next 90 days:

• CMS MA prior auth enforcement: The new SLA requirements (72h urgent / 7-day standard) take effect this year. How MA plans respond — and whether enforcement is real — will shape denial volume for the back half of 2026.
• Commercial plan AI deployment: UnitedHealthcare, Cigna, and Aetna have all signaled continued investment in AI-assisted claim review. Expect denial specificity to increase, not decrease.
• Dental network consolidation: The continued rollout of Zelis/Maverest repricing across formerly direct-contract Humana and BCBS plans is a live underpayment risk for DSOs and group dental practices.

The survey data is telling you what practitioners already know in their bones: the payer environment is the primary constraint on revenue cycle performance right now. The organizations that treat that as a systems problem — and build the intelligence infrastructure to fight back — will outperform on collections through 2026 and beyond.

Published by RevCycleAI Research · February 23, 2026