Payers deny claims faster than practices can appeal, consultant Taya Gordon says

Payers can now review and deny a claim faster than most practices can appeal one, and that gap, more than neglect, is why denials pile up in accounts receivable, according to one revenue cycle consultant.

Shawntea "Taya" Gordon, MBA, FACMPE, CEO of Atlas & Perpetua Healthcare Consulting, told Physicians Practice at the 2026 MGMA Annual Conference in San Antonio that practices have slipped into a habit of reacting. "So many have gotten used to firefighting and reacting to whatever happens in the moment," she said.

She compared it to losing your grip on a shopping cart at the top of a hill. "You are running to catch it, but it's picking up speed because now it's got gravity behind it, and you can't catch up with that momentum," she said.

Payers using AI have made the hill steeper. "They're able to review things faster, deny things faster, and we're still pretty manual in terms of our appeals efforts," Gordon said. In an August interview, she named unmanaged denials and claims sitting in AR as the leaks she finds most often.

Practices have said as much to MGMA. Claim denials and automatic downcoding both rank among the top five burdens in MGMA's 2026 Regulatory Burden Report, and three of the top five tie to Medicare Advantage. MGMA is now shopping draft legislation that would bar Medicare Advantage plans from automatically downcoding claims, with AI and other algorithms named in the text.

Retire the 30-day bucket

Gordon would like practices to stop reviewing days in accounts receivable in 30-day buckets. "Our payers respond now within 14 days, almost all of them, because it's all electronic," she said.

She would also like to see administrators stop pushing back the time they set aside to work AR. Conference speakers tell attendees to block that time on the calendar, she said, and then the meeting arrives. "I need to bump this meeting. I can't do this right now. I need to push this further out," she said, describing the pattern. "Those are the things that are keeping them stuck where they're at."

The numbers that tell the story

Gordon's short list of benchmarks starts with net collections ratio and days in AR, read alongside charge lag. She described a group whose lead physician was furious that his team needed 30 days to get a claim out the door. "So we split it up and saw how long it took him to close his notes first," she said.

She also watches the share of AR older than 120 days, broken out by payer. A plan with its entire balance past 120 days, she said, is "a very telling and immediate work queue item."

"People don't look at them because they don't always know how to get to the data," she said. "But they have access to it right now."

Know your numbers before you negotiate

The same data matters when a payer pitches a value-based contract or a practice decides it needs to renegotiate. Gordon said the first questions are internal: "Are you collecting all the money you're already due to receive? How fast are you collecting that money? How hard does your team have to work on appeals to get that money in the door?"

Without those answers, she said, a practice can't judge the deal in front of it. "You could be negotiating a deal that actually isn't good for you because you don't actually know where you stand."

A six-month downcoding check

Her one assignment for administrators back from San Antonio: Pull the CPT codes billed over the last six months and compare them with the codes paid on the same claim IDs.

"If those are different, it's probably because you're being downcoded," Gordon said. "Some payers are telling you, some payers are just doing it, and it comes through looking like a paid claim."

What's next

The bigger financial hit could come from Medicare. The 2027 Medicare Physician Fee Schedule proposed rule would pay every service but the most expensive at 50 percent when an office visit falls on the same day as a procedure with a 0-, 10- or 90-day global period. MGMA has pressed CMS to drop the cut, and the final rule is expected around Nov. 1.

Gordon said she has been asking practices how they would handle the cut, and the answers split by geography. A metropolitan physician told her patients would be limited to one problem per visit. A rural group told her it would absorb the loss rather than send patients who drive hours back for a second appointment.

"It's just interesting to see how different it's being interpreted by different groups," she said.