About 90 percent of claims processing expenses are tied to staff time, Ingram says, citing manual follow-up, resubmissions, and appeals as primary drivers. For health systems with already constrained administrative teams, those demands intensify both financial and workforce pressures.

A push for transparency and enforcement
Premier is urging CMS to strengthen enforcement and expand transparency, particularly within Medicare Advantage. The organization has called on CMS to collect and publicly report data on payment delays and denials, giving beneficiaries clearer insight as they compare plans.
“Patients deserve greater transparency into how their premium dollars are being used,” Ingram says. “Consumers want to understand not only how often their plan denies or delays claims, but also how often those denials stem from their provider’s own documentation errors.”

Such data would also give CMS a clearer view of whether Medicare Advantage plans are meeting contractual obligations, including network adequacy. While plans may advertise broad provider networks, Premier argues that delayed or inadequate payment can weaken those networks in practice, limiting reliable access to care.

Inside the Prompt and Fair Pay Act
If enacted, the Prompt and Fair Pay Act could begin reshaping Medicare Advantage claims processing within its first year, with early changes focused on implementation.

Ingram says the legislation’s payment parity provisions would prompt contract renegotiations between plans and providers, with payment models adjusting accordingly. As those agreements evolve, shifts in network participation could follow.

Once prompt-pay requirements are in place, providers would likely see fewer claim backlogs and greater clarity around claim status. For patients, that could translate into more predictable billing, fewer unexpected delays, and more consistent access to participating providers.

“The bill holds potential for substantially reducing friction and improving relationships between payers and providers in the long term,” Ingram says.

Absent structural reform, Premier’s data suggests overturned denials should not be mistaken for progress. Instead, they remain a warning sign of a system breaking down long before care is delivered.

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