Appeals and grievances have always been part of healthcare operations. What stands out is not just how appeals are handled, but how few denied cases ever make it into the appeals process. That should matter to anyone responsible for operations, cost, or performance.
Recent data shows just how much friction exists in the system. In Medicare Advantage, more than 80% of prior authorization denials are ultimately overturned when appealed, yet only a small percentage of beneficiaries ever go through the appeals process. Earlier CMS and OIG findings showed similar patterns, with roughly 1% of denials appealed at the first level despite high overturn rates.
That should get every payer’s attention. If a meaningful number of decisions can be overturned, but only a small portion ever reach appeal, that is not just a process issue. It means you do not have full visibility into where decisions are breaking down or how often they should be challenged.
Most organizations focus on how appeals are processed: turnaround times, compliance clocks, documentation, and escalation paths. Those things matter, but they are not the whole story. That view assumes the right cases are actually entering the system in the first place.
Appeals and grievances are usually treated as a downstream workflow. In reality, they expose upstream issues in how decisions are communicated, how cases are understood, and how easy it is for providers to actually move a case forward.
The real risk shows up in experience and reputation
It is easy to frame this as a compliance issue, especially with CMS increasing oversight. But most operators are not losing sleep over penalties. They are focused on cost, star ratings, and credibility in the market.
When appeals and grievances break down, the consequences do not stay contained within operations. They become visible in ways that are difficult to control. Delays in care, confusion around status, or decisions that take too long to resolve all shape how members and providers perceive a payer. In more serious cases, those delays can have real clinical implications, and that is where reputational damage accelerates quickly.
At that point, it is no longer about whether you made the right decision. It is about whether you made it fast enough to avoid downstream impact.
Workflow breakdowns make the problem harder to manage
From an operational standpoint, most of the challenges are not rooted in a lack of intelligence or effort. They come down to workflow. By the time a case reaches this stage, the process is already under pressure. Appeals and grievances move through a series of steps that often span multiple teams, systems, and handoffs.
Many organizations lack a clear, end-to-end view of where cases sit, who owns them, and where bottlenecks exist.
Without that visibility, teams are forced to rely on manual tracking and individual follow-ups. That slows everything down and introduces inconsistency. It also makes it harder to prioritize effectively.
When that happens, teams stop managing a process and start chasing work. That is where delays and variability start to compound.
Rising volume is colliding with resource constraints
For the cases that do make it into the system, volumes are increasing. Members and providers are becoming more aware of their ability to appeal decisions, and more are beginning to use those channels. Early signals at both the federal and state levels point to rising appeal activity and meaningful overturn rates when those appeals are pursued.
This creates tension for operations leaders, with growing demand and higher expectations around turnaround time on one side and constraints on cost and staffing on the other. Simply adding more people to manage the workload is not a sustainable solution, especially as regulatory and market pressures continue to evolve.
Many organizations are still operating across fragmented systems, which makes it difficult to maintain a consistent view of where cases are and how they are progressing. That lack of visibility directly impacts both speed and decision-making.
There is a lot of discussion around AI in this space. The reality is simple. If you do not understand your workflow, you will just scale the same inefficiencies faster.
Appeals and grievances reflect more than process performance
For many organizations, this is one of the most visible moments in the member journey. When something goes wrong, this is where it shows up. It is not buried in the background. It is front and center for the member, the provider, and anyone else involved in that case.
What this process really reflects is how well your organization operates under pressure. Can your teams coordinate across functions, or does the case sit while people figure out ownership? Can you move quickly, or does it stall in handoffs and manual follow-ups? Can you actually get to resolution, or does the process drag on longer than it should?
That is why appeals and grievances carry more weight than they used to. They are not just an operational requirement. They are one of the clearest indicators of how your organization performs when it matters most.
The bigger signal appears before the appeal begins
That visibility makes it easy to focus on what happens after an appeal begins. But the more important signal often appears earlier.
When a large share of denials can be overturned but only a small percentage are ever appealed, it points to a disconnect in how the process is understood, accessed, or trusted. That gap has implications for operations, for compliance, and for how members and providers experience the system as a whole.
From an operational standpoint, the takeaway is straightforward. If the right cases are not entering the process, improving turnaround times alone will not fix the problem.
Improving workflow, visibility, and coordination remains critical. So does reducing the manual burden on teams responsible for managing these cases. But organizations that look only at what happens after an appeal is filed risk missing the larger issue.
Appeals and grievances reflect how well a health plan functions under pressure. They also show how effectively your organization can surface, prioritize, and resolve the cases that matter most.
As expectations continue to rise and scrutiny increases, the organizations that pay attention to both sides of that equation will be in a stronger position to respond, adapt, and earn trust over time.
Photo: narvo vexar, Getty Images
Elevsis Delgadillo is the Senior Vice President of Customer Success at Keenstack, the professional services consulting firm that helps companies unlock the full potential of ServiceNow. In this role, he leverages his deep healthcare IT expertise to ensure exceptional client outcomes.
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