
Why Commercial & Medicare Advantage Will Be the Next Denial Battleground
At Ember we crunch millions of claims a month, and one reality is clear: traditional Medicare isn’t the headache—commercial and MA plans are. The 2028 Medicaid cuts will turbo-charge that trend.
The Shift No One Is Pricing In
- Margin Gaps Roll Uphill
When $50 B in Medicaid support disappears, hospitals look to commercial contracts to plug the hole—so payers crank up prior-auth and DRG downgrades. - MA Plan Economics Tighten
Star-rating penalties + risk-adjustment claw-backs mean every diagnosis code will face AI-driven audits. Expect denial rates to jump 15-20 % by 2029. - Code-Level Scrutiny
NLP bots will read every clinical note. Minor phrasing gaps today become compliance flags tomorrow.
How Ember Turns Scrutiny Into Advantage
Average results across our client base, 2024-25.
Checklist
- Audit denial root-causes by payer & CPT now.
- Automate clinical-coding reconciliation—kill “up-code” flags before they hit the scrubber.
- Negotiate AI-backed risk corridors to show plans you self-police quality.
- Deploy real-time eligibility pings to manage MA churn.
Equip your RCM with AI today, or drown in denials tomorrow. Let’s build friction-free reimbursement together: Book Demo
Lynn Hsing is a recognized leader in healthcare marketing. Having worked closely with health systems and providers, Lynn brings a nuanced understanding of the challenges they face — from administrative burden and claim denials to reimbursement delays and staff shortages. This firsthand insight has shaped Lynn’s ability to translate complex AI solutions into meaningful value for healthcare organizations.