Managed Care
Health Systems Report Claims Automation Gap with Payers Creating Revenue Cycle Pressure
Revenue cycle executives at 17 health systems report that payers are now reviewing and denying claims at volumes and speeds that providers cannot match, creating what they describe as an unsustainable financial asymmetry. The automation gap affects providers' ability to respond to denials and prior authorization requests in real time. The imbalance is intensifying as payers deploy AI and automation tools faster than health systems can adopt corresponding technology. For Medicaid managed care organizations and their provider networks, this dynamic accelerates existing tensions over claims processing, prior authorization burden, and network adequacy tied to provider financial stability.
Why it mattersMedicaid MCOs face heightened provider network stability risk and state scrutiny of claims processing practices as the automation gap widens provider losses and administrative burden.