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Getting paid certainly isn’t getting any easier for today’s physicians. In fact, healthcare payer challenges may continue to intensify as payers leverage artificial intelligence (AI) and revenue cycle management automation when processing claims. In fact, 84% of health insurers report they currently use AI and machine learning in some capacity, according to a recent survey conducted by the National Association of Insurance Commissioners.
“Payers are increasingly using automation to downcode, reject, and flag claims often without human review. That means denials are happening faster and more frequently,” explained healthcare consultant Aimee Heckman during a recent Tebra webinar, Getting paid: How to capture every dollar in 2026.
Seventy-six percent of healthcare financial leaders say denial management is their organization’s most time-consuming revenue cycle task, according to a recent survey conducted by Tebra.
“Denial management is time-consuming, and it can be costly, both from a staff perspective and potentially revenue loss,” said Heckman. “It's critical to identify patterns in denials and, whenever possible, fix whatever is causing the denial further up in the visit cycle.”
Heckman said payers will continue to use AI and revenue cycle management automation not only for denials but also to flag claims for takebacks, referring to retroactive claim payment reversals that payers initiate months or even years after paying a claim, noted Heckman. “This means even a clean claim isn’t always safe,” she added.
In this article, we’ll explain how independent practices and billing companies can address anticipated payer challenges using proactive steps to increase compliance.
How to address healthcare payer challenges: Take proactive steps now
Prevention will be every medical practice’s best defense against denials, said Heckman. “My advice is to start by triaging your top 3 denial types and then build simple SOPs [standard operating procedures] for each of those,” she added.
Preventing takebacks and denials starts with ensuring accurate data entry, Heckman emphasized. “Typos in the member ID, the name spelling, or plan names are still one of the biggest drivers of front-end rejections,” said Heckman. “One thing that helps streamline all of this is letting patients verify their info through a kiosk or patient portal. That way, staff can spend less time typing patient data in and potentially getting it wrong and more time catching issues before they turn into denials.”
"Practices need solid workflows that confirm primary and secondary coverage before the patient receives services."
Next comes accurate coordination of benefits (COB), she explained. “Practices need solid workflows that confirm primary and secondary coverage before the patient receives services,” she said. “Keeping up with Medicaid changes can be particularly tricky because some states allow Medicaid recipients to change their HMO plan every 90 days, some more often. To be safe, ask to see their card at every visit and run that eligibility.”
Finally, practices can’t overlook the importance of accurate medical coding and documentation, Heckman said. She offered these tips to prevent takebacks and denials:
- Document medical necessity. Documentation must clearly and concisely reflect the reason why a physician performs and bills each service.
- Know when to use modifier 25. Many payers now use machine learning to detect outliers in code usage and modifier pairing. For modifier 25, ensure documentation clearly supports a distinct evaluation and management service separate from the procedure performed.
- Only report relevant diagnoses. Claims should only include relevant comorbidities and anything the physician assesses or manages during the visit. In addition, ensure providers know how to report the most specific diagnosis code as well as the differences between ‘other specified’ and ‘unspecified.’ Check out Tebra’s easy-to-use ICD-10-CM code glossary to boost your compliance.
- Use templates, AI scribes, and copy and paste documentation with caution. Review and update all information to ensure accuracy and avoid overlooking abnormal findings and contraindications.
Other ways to address healthcare payer challenges in 2026 and beyond
Heckman provided these additional tips:
- Maximize revenue cycle automation. “These systems are not just ‘nice to have’s’ anymore,” she said. “They're how you can get paid faster and with less friction.”
- Retain top talent. “More practices are connecting the dots between retention and technology,” Heckman said. “If your team is spending hours chasing COB updates or reworking denials, you know it’s a recipe for burnout. Automating those tasks doesn’t just improve revenue; it improves job satisfaction.”
- Standardize revenue cycle management policies and procedures, including policies around point-of-service patient collections. Then revisit them as payers, services offered, and providers change.
"[Revenue cycle automation] systems are not just ‘nice to have’s’ anymore. They're how you can get paid faster and with less friction."
Leverage ChatGPT to improve revenue cycle management
During the Tebra webinar, Heckman cited several examples of how practices and billing companies can leverage ChatGPT and similar revenue cycle AI tools (with oversight) to improve revenue cycle performance and address healthcare payer challenges:
- Create patient-friendly cost explanations and payment plan scripts. Use these scripts to improve collections by helping staff confidently discuss out-of-pocket costs.
- Draft appeal letters. For example, ask ChatGPT to create a letter template for appealing a claim denial due to lack of authorization when the authorization is already on file. However, she cautions providers to always de-identify information used in any inquiries.
- Generate front-desk eligibility and authorization checklists. Then tailor them to each payer, cutting preventable denials before claims are submitted.
- Review and enhance SOPs. Ask ChatGPT to rewrite documents in plain language or flag steps that might be missing.
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Look ahead with a focus on compliance
With increasingly complex payer policies in 2026, practices must do the following tasks to protect revenue:
- Enhance front-end accuracy
- Monitor denials and underpayments, and
- Ensure strong documentation to protect revenue
In addition, leveraging revenue cycle automation can help avoid cash flow issues. Now is the time to address healthcare payer challenges by exploring ways to improve people, processes, and technology. Take a free interactive, self-guided tour today to see how Tebra's automated medical billing solutions help you get paid faster.
For more tips on navigating payer challenges in 2026, watch the full webinar recording below.
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