You Can't Appeal Your Way Out of This
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denial rate
Written By Craig Mattson, Principal Architect
Payers are deploying AI at scale. Denial rates are rising. Coincidence?
Denial rates across commercial and government payers are climbing, and the pace is not slowing down. This is not an accident or a side effect. Payers have built infrastructure specifically designed to deny faster, more consistently, and at a scale no human review process can keep up with. AI didn't create the incentive to deny. It just removed the bottleneck.
For providers, the math is brutal. More denials mean more appeals, more appeals mean more people and more hours spent chasing money that was already earned. The industry knows this. What it hasn't done is clearly name the deeper problem.
The Current Response Isn't Working
Given how the industry has always responded, the instinct has been to add more staff, more processes, and more appeals. That made sense when the problem was manageable with human intervention. It doesn't anymore.
When it's time to transmit a well-formed appeal at the speed and volume the problem actually demands, there is nothing on the other side to receive it: no standardized channel, no machine-readable intake, no automated receiver. The payer sends denials at machine speed, and hospitals and health systems are forced to respond by fax.
That is not a staffing problem. It is a technology gap that payers have no incentive to close. Every appeal that stalls, expires, or disappears into a portal is a denial that holds. The friction they’ve created is the entire point.
The Right Problem to Solve
Fighting denials after they issue means you are already playing on the payer's terms. You’re never going to win the game if someone is constantly changing the rules. The only leverage is upstream.
We know, a clean claim doesn't get denied. Intelligence that understands payer policy before submission, that flags risk before adjudication, that informs how the claim gets constructed — that is where margin gets protected rather than recovered after the fact. The goal is not to build a faster fax machine. The goal is fewer denials in the first place. The way to achieve that goal is clean claims from the start.
What We're Building
We understand this problem because we are inside it right now.
The gap is technological, but it is also a matter of knowledge and insight. You have to understand how payers think, how policy gets applied, and where the risk actually lives in a claim before you can build something that addresses it. The technology without that context is just automation pointed in the wrong direction.
We are building the intelligence to know what to act on and how — not to chase denials faster but to stop more of them from happening. The payer's system learns and improves every week. Ours does too.
We are not waiting for payers to build a fair fight. We are working to remove the need for one.
