Why You’ll Never Outpace the Payers — and What to Do Instead

The Race Providers Can’t Win

Revenue cycle leaders don’t just encounter payer changes as formal announcements or clear policy shifts. They also become apparent when claims that once moved through cleanly now pause without explanation. Authorizations that met requirements weeks ago no longer align with billing outcomes. Payment timing becomes unpredictable when the rules change behind the scenes.

This isn’t a matter of responsiveness or effort. Payers adjust review logic, documentation thresholds, and claim routing inside automated systems that operate outside the visibility of provider teams.1,2 Those changes increase the effort required to keep revenue moving. Without a clear rule set to work from, revenue becomes harder to forecast with confidence. The challenge for providers isn’t keeping pace with payers but keeping revenue operations effective as payer rules keep changing.

How Payers Stay Ahead

Payer changes create disruption, whether or not they are announced. From the provider side, these changes appear inconsistent. From the payer side, they reflect routine system behavior driven by updates to review logic, payment rules, and automated checks embedded in their platforms.1,3 The result is more claims paused midstream and longer resolution cycles.3,5,6 Staff attention shifts toward figuring out what changed instead of moving work forward,4 which limits a practice’s ability to act intentionally.

Why Providers Can’t Compete at the Same Speed

When payer behavior changes, the instinct is to respond faster. Teams adjust workflows, add checkpoints, and create exceptions to keep claims moving, and those changes feel necessary. The problem is, they introduce variation that makes outcomes harder to interpret.

Speed creates motion, but it doesn’t create control. Each rapid adjustment adds another layer to the process, obscuring the difference between internal breakdowns and a payer-driven decision. As a result, more effort goes into the work, with less certainty about what caused the issue.  Trying to compete on pace pulls organizations away from building the structure needed to see what’s happening inside the revenue cycle.

What to Do Instead: How Providers Can Reclaim Control

Organizations that manage reimbursement well limit how far payer disruption travels. Revenue work runs through a streamlined structure, so when something breaks, teams know where to look.4 Consistency in the early stages of the process, including documentation, coding, and authorization, reduces uncertainty about where problems arise.  When denials occur, the reason is obvious.7

Follow-up changes as well. Instead of working on every open item the same way, teams pay attention to timing. A claim that stalls early signals a different issue than one delayed after adjudication. Contract performance receives the same treatment. Expected reimbursement is always reconciled against payment, not assumed. When underpayment appears, it’s visible without requiring escalation. The work becomes more precise because the structure supporting it is stable.

Stop Running the Wrong Race

Payers will continue to change how claims move through their systems, and they are unlikely to settle into a predictable pattern. Organizations that protect revenue performance do so by strengthening their internal structure. When the work is built that way, it becomes manageable for practical reasons rather than relying on urgency or heroic effort to keep things moving.

References

1.  Healthcare Finance News. Class-action lawsuit against UnitedHealth’s AI claim denials advances. Published November 2023. Accessed March 2026.
   https://www.healthcarefinancenews.com/news/class-action-lawsuit-against-unitedhealths-ai-claim-denials-advances
2.  Modern Healthcare. Aetna, Cigna downcoding policies explained. Published 2024. Accessed December 2025.
   https://www.modernhealthcare.com/insurance/mh-aetna-cigna-downcoding-policy-explainer/
3.  American Hospital Association. Payer denial tactics: How to confront a $20 billion problem. AHA Center for Health Innovation Market Scan. Published April 2, 2024. Accessed December 2025.
   https://www.aha.org/aha-center-health-innovation-market-scan/2024-04-02-payer-denial-tactics-how-confront-20-billion-problem
4.  American Medical Association. Revenue Cycle Management Guide. Published 2024. Accessed December 2025.
   https://www.ama-assn.org/system/files/revenue-cycle-management-guide.pdf
5. Experian Health. Healthcare claim denials statistics: State of claims report. Published 2024. Accessed December 2025.
   https://www.experian.com/blogs/healthcare/healthcare-claim-denials-statistics-state-of-claims-report/
6. Experian Health. Experian Health’s 3rd annual state of claims survey finds denial rates continue to rise. Press release. Published January 2025. Accessed December 2025.
   https://www.experianplc.com/newsroom/press-releases/2025/experian-health-s-3rd-annual-state-of-claims-survey-finds-denial
7. ICD10monitor. Denials management in 2025: Proactive strategies beyond appeals. Published 2025. Accessed December 2025.
   https://icd10monitor.medlearn.com/denials-management-in-2025-proactive-strategies-beyond-appeals/