When Dr. Heather Signorelli picked a 2026 health plan for her family, she could compare deductibles, copays and out-of-pocket maximums in minutes. What she couldn’t see was what happens when someone actually gets sick: what’s covered, what needs prior authorization, and what counts as medically necessary. Prices are public now. The rules that decide whether a claim gets paid are not. In this solo episode, Heather explains where that gap comes from, how it ends up in your practice as denials and delays, and what needs to change.
The Form Shows the Basics, Not the Rules
The standard Summary of Benefits and Coverage only shows costs for a few simple cases, like having a baby or a simple fracture. A breast cancer example was in the original 2011 proposal and was taken out. When Heather ran her own benefits summary through AI, “no benefits if not pre-approved” came up again and again, with nothing saying what approval actually takes.
Who Really Decides What’s Medically Necessary
You make the first medical necessity decision. The payer makes the second one, and theirs is the one that counts. Many plans use proprietary criteria from InterQual or MCG that are only shared on request. One example: a patient with years of worsening arthritis can be denied a shoulder replacement because their last round of PT was more than 12 months ago.
What the Numbers Say
In a 2025 AMA survey, physicians reported about 40 prior authorizations a week, taking roughly 13 hours of physician and staff time. 95% said prior auth delays necessary care, and 26% said it led to a serious adverse event for a patient. Prior auth data is now public for Medicare Advantage, Medicaid managed care and marketplace plans, and it shows something important: few denials get appealed, and many of the ones that are appealed get overturned.
The Fix: Physicians Set the Minimum Standard
Heather makes the case for a physician-defined minimum level of coverage set nationally or by state, not insurer by insurer. Then plans would have to compete on price, quality and outcomes.
The 2027 HMO Shift
Medicare Advantage is moving toward more HMOs and fewer PPOs. That means more referrals required before specialist visits, and more denials when they’re missing.
Three actions before January:
- Pull every Medicare Advantage patient booked for January and February and check their 2027 plan type in the payer portal.
- For anyone moving to an HMO, get the PCP referral before the visit.
- Make sure your team is appealing denials. The data shows it’s worth the work.
Episode breakdown
00:00 A physician picking a health plan for her family
01:30 What the Summary of Benefits leaves out
03:45 Running a benefits summary through AI
04:50 The conference conversation on utilization management
07:10 Why plans can’t be compared on what really matters
08:45 The case for a minimum standard of coverage
12:00 Who decides what’s medically necessary
13:30 The AMA prior authorization survey
14:15 Proprietary criteria and the shoulder replacement example
16:00 Biomarker mandates and coverage standards in the lab world
19:00 Prior auth data made public for the first time
21:30 Medicare Advantage moves to HMOs in 2027
23:00 Your January checklist
Resources
- Billing Performance Scorecard: score your billing operation and get an action plan built from your results. https://eligibility.natrevmd.com/natrevmd-billing-performance-scorecard-actionable-plan
- Free Metrics Audit Review: a NatRevMD review of your key revenue metrics, best if your Scorecard shows 2+ red areas. eligibility.natrevmd.com/metrics-audit-natrevmd
- NatRevMD: natrevmd.com
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