CMS in 2024 documented a striking gap at the center of the prior authorization system: Medicare Advantage plans, on average, overturn 80% of denied claims when they are appealed, while only 4% of denied claims ever reach that stage.
A review article published in the May 2026 issue of Gastroenterology & Endoscopy News by clinicians at Penn Medicine’s Perelman Center for Advanced Medicine in Philadelphia offers one of the more detailed accounts yet of what it takes to close that gap at the practice level.
The article, authored by Lauren Wilson, MSN, CRNP; Anna Jung, PharmD; and Chisom Amaeze, PharmD, describes the development and expansion of a dedicated prior authorization denial team at Penn Medicine’s outpatient gastroenterology clinic, beginning in spring 2021 and evolving through the present.
The model reassigned appeal responsibilities from physicians to advanced practice providers and pharmacists, standardized the documentation process, and built a library of more than 15 appeal letter templates covering the most common denial scenarios.
The scale of the problem the model was designed to address has grown sharply. A 2021 survey of American Gastroenterological Association members found that 89% reported an increase in prior authorizations over the prior five years, 96% called them burdensome and 99% said they hindered appropriate care. A 2022 study found that 90% of insurance policies are inconsistent with AGA guidelines, and that prior authorizations created an average treatment delay of 10.2 days — with complex cases averaging 24.6 days. Those delays corresponded with a 13% increase in IBD-related healthcare utilization, including emergency department visits, hospitalizations and surgery.
At the Penn Medicine clinic, prior authorization denials requiring appeal ran to approximately 29 per month in early 2021. By late 2022, that volume had risen to between 35 and 50 per month. The most frequent denial reasons were dose escalation and optimization deemed off-label — clinical decisions guided by therapeutic drug monitoring and loss of response data that insurers were nonetheless declining to cover.
The original workflow asked the IBD-focused gastroenterologist, APP and PharmD to share responsibility for peer-to-peer calls and letters of medical necessity while also managing their primary clinical roles. That arrangement was common across GI practices — and, the authors note, structurally unsustainable as denial volumes grew.
The new model designated specific staff to own the denial process. The pharmacy team absorbed the work of completing required forms, submitting appeals, following up with insurance companies and coordinating with the patient and specialty pharmacy or infusion center. Pharmacy technicians spent an average of 20 to 90 minutes per denial on follow-up calls alone. The APPs handled peer-to-peer calls and letters of medical necessity as the primary point of clinical escalation.
The workflow also addressed the documentation problem that makes individual appeals labor-intensive. Without standardized templates, writing a single appeal letter took 45 to 60 minutes. With them, the same letter took 20 to 30 minutes. The template library grew to cover more than 15 distinct denial scenarios — from standard new-therapy starts to nuanced situations such as tuberculosis testing requirements before medication initiation and denials tied to subtherapeutic drug monitoring levels with antibody formation.
Templates were structured so that only patient-specific information required manual addition. They embedded text on the clinical risks of uncontrolled disease, extended corticosteroid use and inappropriate insurer-suggested medication substitutions, along with sections for supporting literature citations. The standardization made appeals faster without sacrificing clinical specificity — and, the authors found, made them more effective.
Over the first two years of the model, use of dedicated staff and standardized templates led to an approximately 50% decrease in the average time spent writing an appeal. The overall volume of appeals did not decline — it continued to rise — but the time per appeal fell, and the appeal process became something the clinic could absorb without displacing clinical work.
A survey of physicians and nurses at the first site found that 100% reported the dedicated staff and workflow change were helpful and led to improved physician satisfaction. The model rated 9.79 out of 10 on a helpfulness scale at site one and a perfect 10 at a second site where it was expanded in summer 2023.
The expansion to a second site also prompted the model’s most significant structural evolution: following the addition of a full-time IBD pharmacist, all appeal letter responsibilities shifted to the pharmacy team in summer 2023. The authors describe this PharmD-only model as more scalable and more resilient to staffing changes than the earlier shared arrangement.
The survey at the second site, while broadly positive, also surfaced a limitation that the model’s own success helped create: even with dedicated staff, providers indicated they needed more assistance and resources as denial volume continued to climb. The infrastructure built to manage appeals had not reduced the underlying pressure driving them.
The article situates the Penn Medicine experience within a broader policy landscape that, so far, has not materially shifted the appeal dynamic. The ACA requires that prior authorization decisions for Medicare Advantage plans meet specific timeliness standards, and CMS has taken steps to mandate electronic prior authorization processes. But the authors note that those reforms have not addressed the fundamental mismatch between denial volume and provider capacity to contest it — the same gap that the 4% appeal rate reflects.
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