PayerWatch

As artificial intelligence becomes increasingly embedded in healthcare claims processing, hospitals face mounting challenges from insurance denials, diagnosis downgrades, and reimbursement disputes. Insurers' use of automated review systems has raised concerns about transparency, clinical oversight, and whether payment decisions receive meaningful human evaluation. According to a 2026 KFF analysis, Medicare Advantage insurers denied approximately 4.1 million prior authorization requests in 2024, representing 7.7 percent of nearly 53 million determinations. Only 11.5 percent of those denials were appealed, yet 80.7 percent of appealed denials were partially or fully overturned.

As insurers expand their use of automation and hospitals struggle to challenge increasingly complex denials, how can healthcare providers strengthen their appeals strategies while protecting patients' rights to necessary care?

On this episode of Deny This, a PayerWatch podcast, host Brian McGraw welcomes Dr. Kendall Smith, Chief Medical Officer and Chief Physician Advisor at PayerWatch, to examine the growing imbalance of power between insurers, healthcare providers, and patients. Their conversation explores AI-assisted denials, disputed clinical validation audits, the importance of human oversight in appeals, and how patient representation could offer hospitals a stronger pathway to challenging unfavorable coverage decisions.

Key Takeaways from the Conversation

• AI-driven denials and diagnosis downgrades are increasing pressure on hospital revenue. Dr. Smith discusses insurer practices involving the removal of comorbidities and major comorbidities from claims, potentially reducing reimbursement despite documented clinical complexity. He highlights disputed sepsis denials and concerns about automated medical necessity reviews, emphasizing that hospitals need accurate, defensible documentation and a willingness to escalate appeals when appropriate.

• Human oversight remains essential as AI transforms the appeals process. While AI can efficiently identify relevant clinical information within lengthy medical records and accelerate appeal preparation, Dr. Smith argues that experienced physicians, nurses, and coding specialists must review and validate its conclusions. He advocates a human-in-the-loop approach that combines automation's efficiency with professional clinical judgment, accountability, and transparency.

• Patient representation could strengthen appeals, but hospitals need enterprise-wide systems to support it. McGraw and Dr. Smith explore how an Appointment of Representative (AOR) can authorize qualified advocates to pursue certain appeals on a patient's behalf, potentially opening pathways to independent review and administrative hearings. However, implementing these programs requires coordinated workflows, staff education, deadline tracking, and clear accountability across hospitals, clinics, and outpatient facilities to protect patients from losing valuable appeal rights.

Dr. Kendall Smith serves as Chief Medical Officer and Chief Physician Advisor at PayerWatch, where he focuses on healthcare appeals, clinical validation, medical necessity disputes, and strategies for challenging insurance denials. Through his work with hospitals and health systems, he helps healthcare organizations navigate complex reimbursement disputes and strengthen their appeals processes. Smith also contributes to industry education through webinars and discussions addressing payer accountability, clinical documentation, and the evolving role of artificial intelligence in healthcare reimbursement.

As artificial intelligence becomes increasingly embedded in healthcare claims processing, hospitals face mounting challenges from insurance denials, diagnosis downgrades, and reimbursement disputes. Insurers' use of automated review systems has raised concerns about transparency, clinical oversight, and whether payment decisions receive meaningful human evaluation. According to a 2026 KFF analysis, Medicare Advantage insurers denied approximately 4.1 million prior authorization requests in 2024, representing 7.7 percent of nearly 53 million determinations. Only 11.5 percent of those denials were appealed, yet 80.7 percent of appealed denials were partially or fully overturned.

As insurers expand their use of automation and hospitals struggle to challenge increasingly complex denials, how can healthcare providers strengthen their appeals strategies while protecting patients' rights to necessary care?

On this episode of Deny This, a PayerWatch podcast, host Brian McGraw welcomes Dr. Kendall Smith, Chief Medical Officer and Chief Physician Advisor at PayerWatch, to examine the growing imbalance of power between insurers, healthcare providers, and patients. Their conversation explores AI-assisted denials, disputed clinical validation audits, the importance of human oversight in appeals, and how patient representation could offer hospitals a stronger pathway to challenging unfavorable coverage decisions.

Key Takeaways from the Conversation

• AI-driven denials and diagnosis downgrades are increasing pressure on hospital revenue. Dr. Smith discusses insurer practices involving the removal of comorbidities and major comorbidities from claims, potentially reducing reimbursement despite documented clinical complexity. He highlights disputed sepsis denials and concerns about automated medical necessity reviews, emphasizing that hospitals need accurate, defensible documentation and a willingness to escalate appeals when appropriate.

• Human oversight remains essential as AI transforms the appeals process. While AI can efficiently identify relevant clinical information within lengthy medical records and accelerate appeal preparation, Dr. Smith argues that experienced physicians, nurses, and coding specialists must review and validate its conclusions. He advocates a human-in-the-loop approach that combines automation's efficiency with professional clinical judgment, accountability, and transparency.

• Patient representation could strengthen appeals, but hospitals need enterprise-wide systems to support it. McGraw and Dr. Smith explore how an Appointment of Representative (AOR) can authorize qualified advocates to pursue certain appeals on a patient's behalf, potentially opening pathways to independent review and administrative hearings. However, implementing these programs requires coordinated workflows, staff education, deadline tracking, and clear accountability across hospitals, clinics, and outpatient facilities to protect patients from losing valuable appeal rights.

Dr. Kendall Smith serves as Chief Medical Officer and Chief Physician Advisor at PayerWatch, where he focuses on healthcare appeals, clinical validation, medical necessity disputes, and strategies for challenging insurance denials. Through his work with hospitals and health systems, he helps healthcare organizations navigate complex reimbursement disputes and strengthen their appeals processes. Smith also contributes to industry education through webinars and discussions addressing payer accountability, clinical documentation, and the evolving role of artificial intelligence in healthcare reimbursement.

Sepsis remains one of the most consequential medical emergencies facing U.S. hospitals. About 1.7 million U.S. adults develop sepsis each year, and at least 350,000 die during hospitalization or are discharged to hospice, according to the CDC. Awareness is improving—Sepsis Alliance’s 2026 survey found that 78 percent of U.S. adults have heard of sepsis—but only 23 percent could identify all four of the organization’s most common signs and symptoms.

Yet recognizing and treating sepsis is only part of the challenge for hospitals. Different clinical criteria and documentation expectations can complicate reimbursement after care is delivered, creating a difficult question for providers: How can clinicians act quickly enough to save a patient with sepsis while documenting the case thoroughly enough to withstand payer scrutiny?

On this episode of Deny This, a PayerWatch podcast, host Brian McGraw is joined by Dr. Steven Simpson, Chair of the Board of Directors of Sepsis Alliance, and Dr. Kendall Smith, Chief Medical Officer and Chief Physician Advisor at PayerWatch, for a discussion about sepsis recognition, treatment, documentation, denials, and patient advocacy. Simpson explains that Sepsis Alliance has expanded from its roots in public awareness and patient advocacy to work across professional education, governmental advocacy, and research and innovation. The conversation then examines how competing sepsis criteria can affect clinical documentation and why hospitals may need to capture both the clinical reasoning behind the diagnosis and the evidence payers expect to see.

Key Takeaways:

• Early recognition and treatment remain critical to sepsis outcomes. Simpson explains that some patients can progress from an apparently minor infection to septic shock within hours. Because clinicians cannot reliably predict which patients will deteriorate rapidly, early interventions can include blood cultures, broad-spectrum antibiotics, lactate measurement, and IV fluids when hypotension is present.

• Competing sepsis criteria create a documentation challenge for hospitals. The discussion contrasts the infection-plus-SIRS framework associated with earlier sepsis definitions and CMS’s SEP-1 reporting requirements with the Sepsis-3 framework centered on infection-related organ dysfunction and SOFA. Simpson argues that payer reviews can focus on whether SIRS, SOFA changes, and the connection between infection and organ dysfunction were explicitly documented. As a result, he recommends documentation approaches that clearly capture relevant SIRS findings, SOFA scores, organ dysfunction, and their relationship to the underlying infection when clinically supported.

• Denials can ultimately become a patient issue, not simply a hospital revenue issue. Simpson and Smith discuss how denied claims may affect patients financially and emphasize the potential role of patient appeal rights alongside provider appeals. The conversation also explores whether greater patient education around appeals could become another avenue for advocacy, with Simpson saying the discussion had generated ideas for future Sepsis Alliance education on documentation and patient appeals.

Dr. Steven Simpson is Chair of the Board of Directors of Sepsis Alliance and a Professor of Medicine at the University of Kansas in the Division of Pulmonary, Critical Care, and Sleep Medicine. His work spans critical care, sepsis education, advocacy, research, and efforts to improve recognition and treatment of the condition. In the episode, Simpson describes Sepsis Alliance’s work across four primary areas: public awareness and patient advocacy, professional education, governmental advocacy, and research and innovation.

Dr. Kendall Smith is Chief Medical Officer and Chief Physician Advisor at PayerWatch and a Senior Fellow in Hospital Medicine. Throughout his hospitalist career, he has worked extensively in denial and appeals management, utilization review, case management, clinical documentation improvement, and revenue cycle operations. He has helped design and implement CDI programs at organizations including Cleveland Clinic Florida and MedStar Washington Hospital Center and is an AHIMA ICD-CM/PCS approved trainer/ambassador.

The rapid expansion of precision medicine, biologics, and targeted cancer therapies is transforming oncology—but it’s also overwhelming a system not built to keep pace. In the U.S., cancer drugs now account for some of the highest-cost treatments in healthcare, and with that has come a surge in prior authorization requirements and denials. Studies suggest physicians spend nearly two business days per week on administrative tasks like authorizations, contributing significantly to burnout and delayed care.

So how can clinicians ensure patients receive timely, life-saving treatments in a system increasingly shaped by cost controls and automation? And more importantly—can AI become part of the solution rather than just a tool for denials?

On this episode of PayerWatch, host Brian McGraw is joined by Dr. Arturo Loaiza-Bonilla, Co-Founder and Chief Medical AI Officer of Massive Bio, and Dr. Kendall Smith, Chief Medical Officer and Chief Physician Advisor at PayerWatch, for a conversation about oncology denials, prior authorization burden, and the emerging role of AI in appeals and access. Together, they examine how payer decision-making affects cancer patients, why clinical trialsPay are often overlooked in denial workflows, and how human oversight must remain central as AI becomes more common on both sides of the claims equation.

Key Takeaways from the episode:

Oncology denials are uniquely high stakes. Expensive biologics, chemo regimens, and precision therapies are often subject to heavier scrutiny, creating delays that can worsen outcomes and increase financial toxicity for patients.

AI can help, but only with human oversight. The guests discuss how AI can support appeals, clinical trial matching, and documentation, while warning that hallucinated citations and unchecked outputs can undermine care decisions.

Clinical trials should be considered earlier, not later. Instead of treating trials as a last resort or administrative complication, the episode argues they should be more proactively presented as care options that may reduce costs and expand access.

Dr. Arturo Loaiza-Bonilla is a practicing medical oncologist and hematologist, as well as the Co-Founder and Chief Medical AI Officer of Massive Bio. He has spent years working at the intersection of oncology, patient access, and artificial intelligence, helping develop AI-driven tools that connect patients to clinical trials and treatment options. In the episode, he also references his leadership role in a large hematology-oncology network and his long-standing interest in applying data science and computational tools to real-world cancer care.

Dr. Kendall Smith serves as Chief Medical Officer and Chief Physician Advisor at PayerWatch, where he brings deep expertise in chemotherapy and biologic denials, appeals strategy, and payer-provider disputes. His contributions to the episode focus on the practical realities of appeal workflows, the risks and opportunities of AI-assisted case preparation, and the importance of maintaining a human-in-the-loop approach when patient lives are on the line.