The letter says denied. It’s not the first one this month, and the physician already knows how this goes: Read it, feel briefly annoyed, and move on to the next patient, because the last three appeals went nowhere and there’s no real reason to think this one would be different.
Nothing about that moment is really a decision anymore. It stopped being one a while back, and nobody noticed exactly when.
The scale here isn’t in dispute. AMA’s physician survey found 74 percent of physicians report prior authorization denials have increased over the past five years, and physicians complete an average of 39 prior authorizations a week, consuming roughly 13 hours of physician and staff time. Nearly one in three physicians, 31 percent, say requests are often or always denied.
Insurers have made public commitments to fix this. As recently as 2025, roughly 60 health insurers pledged to review medical necessity denials using licensed, qualified clinicians. A year later, only about one in four physicians report those reviews are actually happening that way. This isn’t a physician’s impression of an unfair system. It’s the system’s own trade organization reporting that the promised fix hasn’t shown up.
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When losing enough times becomes a policy
Here’s the finding underneath all of that. Only one in five physicians, 20 percent, always appeals an adverse decision. Among the ones who don’t, two out of three say they believe it wouldn’t succeed anyway, based on what’s happened before.
That’s not a fresh judgment made case by case. It’s a pattern formed by repetition. Lose enough appeals and the instinct stops being “is this one worth fighting” and becomes “appeals don’t work,” a conclusion applied automatically, including to the cases that might have gone the other way.
Sometimes that instinct is correct. Some denials genuinely aren’t winnable, and knowing which fights not to pick is a real, earned skill, not a weakness.
The problem is that the learning happened under duress, decided between patients without time to think it through. That reflex catches the unwinnable cases, but it very likely catches winnable ones too. Nobody can tell which is which anymore, because nobody has the time to look closely enough to find out. MGMA’s own guidance on this puts it plainly: Practices “typically lose because they can’t fight back fast enough,” which is why even well-run teams have shifted toward appealing only “what matters,” a triage decision made under pressure rather than a judgment about merit.
Not losing faith. Running out of hands
The pessimism gets all the attention, but it isn’t the only reason appeals go unfiled, and the other reason matters just as much. Physicians who don’t appeal cite more than doubt about winning: Over half say the patient’s care simply couldn’t wait for the health plan’s approval process, and 55 percent say they didn’t have the staff time or resources to file the appeal in the first place.
That reframes the problem. This was never purely a crisis of confidence that a pep talk or a policy change could fix on its own. Even a physician who believes an appeal would win still needs someone available to actually file it, correctly, on a deadline, while also seeing patients that day. Pessimism explains why physicians stopped trying. A lack of staff time explains why, even when they wanted to try, they often couldn’t.
The twin that looks identical from outside
Picture the denial that might have been overturned, not because the appeal was a sure thing, but because nobody ever actually looked closely enough to find out. It doesn’t get challenged. The patient is told the treatment isn’t covered, or the practice quietly writes off the loss and moves to the next chart. On paper, that reads as a business decision. It was actually resignation, dressed up to look like a choice.
This isn’t a rare misfire. MGMA’s January 2026 poll found denials and appeals are the single biggest thing practices say is quietly costing them money, 48 percent, ahead of every other category, more than billing errors, more than slow collections, more than anything else on the list.
The uncomfortable part is that the difference between a denial that would have won on appeal and one that was correctly left alone is invisible from the outside. Nobody has the time to sort them into two piles, so they all land in the same one, silently, by default.
Bandwidth, not bravery
The fix was never “appeal everything.” That ignores the real, valid instinct that some denials genuinely aren’t worth the fight. The fix is having the bandwidth to actually tell the difference, case by case, instead of defaulting to “probably not” because there’s no time left to check.
A denied claim doesn’t get written off the first time someone says no; somebody looks at it again before the practice gives up the money. The appeal that goes unfiled without a second glance is the one place in the practice where “probably not” gets treated as final, not because the odds are actually worse here, but because nobody’s specifically assigned to take that second look.
The practices closing this gap have someone whose specific job is tracking every denial, checking it against the kind of things that actually predict whether an appeal wins, like missing documentation, a payer with a known pattern of overturning on review, a case that was denied on a technicality rather than true medical necessity, and pursuing the ones worth pursuing. Nobody’s asking that person to out-argue a clinician. They’re making sure the case gets a second look at all, which right now often doesn’t happen even once.
Pull the last ten denials you didn’t appeal. Ask honestly how many of those were decided on the merits, and how many were decided because nobody had the time to look closely enough to decide anything at all.
This essay is cited in the KevinMD record on prior authorization.
Karan Kanwar is the CEO of Central AI and Wing Assistant. Central AI provides an AI operating system for appointment-driven medical practices, handling calls, texts, web chat, and messages around the clock, qualifying patients and booking appointments directly into a practice’s existing systems. It is HIPAA compliant and designed to complement the tools practices already use.
Wing Assistant pairs that technology with skilled virtual assistants who take on the administrative work that pulls teams away from patient care. Kanwar writes on where automation and human support meet in health care operations, and how practice leaders can adopt both effectively. He shares updates on LinkedIn.
