The Denial Finally Says Why

The denials that cost practices the most time tend to be the vague ones. Staff know the answer is no but not what would have changed it, so they make a best guess, resubmit, and wait again while the patient waits too.

For a large share of patients, that situation changed this year. Under the CMS Interoperability and Prior Authorization Final Rule, beginning January 1, 2026, Medicare Advantage plans and Medicaid and CHIP programs, including managed care, must decide urgent requests within 72 hours and standard requests within seven calendar days. They must also provide a specific reason for every denial, regardless of how the request was submitted. The first public reports of each payer’s approval rates and turnaround times were due on March 31, 2026. Drugs of any kind, including drugs given in a clinic under the medical benefit, are excluded. A separate CMS proposal from April 2026 would extend similar rules to drugs, but it has not been finalized.

I regard this as real progress. It is also, at this stage, only information, and information helps a patient when someone acts on it. In the American Medical Association’s 2025 prior authorization survey of 1,000 practicing physicians, released May 13, 2026, practices reported completing an average of 40 prior authorizations per physician per week, taking about 13 hours of physician and staff time, and 79 percent said prior authorization at least sometimes leads patients to abandon recommended treatment. A clearer denial letter still arrives in that same crowded queue.

Send the reason to the person who can resolve it

A specific reason identifies the kind of problem at hand, and different problems belong to different people. Missing clinical documentation should go to whoever assembles the packet with the clinician. A coding issue belongs with billing. A coverage or network denial calls for a conversation with the patient about alternatives. If every denial lands in one inbox and waits for one person, the main effect of the new rule will be a better-explained backlog. I recommend sorting denials by reason on the day they arrive and assigning each to a named owner with a due date.

Track the reasons as well as the volume

A count of denials shows how often they occur. The reasons show why. When the same reason keeps appearing for the same service or the same payer, it usually points to something upstream that can be corrected, such as a question missing from intake, a note template that does not capture what the payer asks for, or a step that gets skipped on busy days. I wrote earlier about where a prior authorization actually waits before it is submitted. An incomplete request generally results in a request for more information, and each exchange costs the patient additional days. Because payers now publish their own figures, a practice can also compare its experience with theirs and see where the two diverge.

Tell the patient what was decided

Patients seldom make a deliberate choice to abandon treatment. More often they hear nothing, call once or twice, receive a different answer each time, and eventually stop calling. Every decision, whether an approval or a denial, warrants a brief message to the patient within a day that covers what was decided, what happens next, who is handling it, and when they will hear again. A denial that comes with a clear next step is a delay. A denial that no one explains is frequently the point at which care ends.

The rule requires payers to explain their decisions. Every practice can ask whether its own workflow can do the same for the patient, by taking the stated reason, turning it into a next step, and making one person responsible for seeing it through.

Sources

• CMS: Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet
• American Medical Association: 2025 prior authorization physician survey (press release, May 13, 2026)
• CMS: Prior Authorization for Drugs Proposed Rule (CMS-0062-P)
• American Medical Association: Delays in reforming Medicare, prior auth harm patients

About the author
Sherry Sayari, MPH, is an Operational Standards Evaluator who has led population health, community outreach, and social services programs. More on the About page.