Why Commercial & Medicare Advantage Will Be the Next Denial Battleground

Lynn Hsing
July 7, 2025
4 min read

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

  1. 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.

  2. 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.

  3. Code-Level Scrutiny
    NLP bots will read every clinical note. Minor phrasing gaps today become compliance flags tomorrow.

How Ember Turns Scrutiny Into Advantage

Without Ember With Ember’s Denial Management Engine
72 hr manual appeals <6 hr automated resubmits
22 % overturn rate 45 % AI-ranked overturns
Static payer rules Real-time denial heat maps & auto-learned playbooks

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

About the Author

Lynn Hsing

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.

Why Commercial & Medicare Advantage Will Be the Next Denial Battleground

Lynn Hsing
July 7, 2025
4 min read

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

  1. 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.

  2. 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.

  3. Code-Level Scrutiny
    NLP bots will read every clinical note. Minor phrasing gaps today become compliance flags tomorrow.

How Ember Turns Scrutiny Into Advantage

Without Ember With Ember’s Denial Management Engine
72 hr manual appeals <6 hr automated resubmits
22 % overturn rate 45 % AI-ranked overturns
Static payer rules Real-time denial heat maps & auto-learned playbooks

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

About the Author

Lynn Hsing

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.