MSSNY PULSE

Turning Insurance Challenges Into $38 Million

Friday, April 17, 2026

Combating Insurance Administrative Burdens in New York

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Colleagues:

One of the most persistent challenges for physicians practicing in New York is navigating the administrative burden imposed by health insurance companies. In many regions, a small number of insurers dominate the market, creating an effective oligopoly that allows them to dictate onerous terms of participation, payment, and claims adjudication. These burdens not only strain physician practices but also directly impact patient care.

Physicians routinely encounter delayed payments, retroactive claim denials, extensive prior authorization requirements, unnecessary record auditing, and frequent “down-coding” of services. Such practices can disrupt care delivery, reduce the efficiency of physician offices, and delay necessary treatment for patients. AMA studies have shown that a significant percentage of physicians report adverse patient outcomes linked to administrative delays caused by prior authorization and other insurer-imposed processes.

Specific administrative challenges include:

Prior Authorization Delays: Patients may experience delays in receiving critical treatments while physicians navigate time-consuming approval processes.
Retroactive Denials and Down-Coding: Insurers sometimes reduce reimbursement for services after claims are submitted, requiring physicians to appeal and creating financial uncertainty.
Network Limitations: Physicians may be forced to join large health systems simply to remain in-network, reducing their autonomy and fragmenting care.
Ghost networks: Healthcare providers have been listed in a health plan’s provider directory who are not actually available to provide care as indicated. These inaccurate directories can delay care and cause high out-of-pocket costs.
Audits and Dispute Resolution: Frequent audits and the need for independent dispute resolution can divert time and resources away from patient care.

These burdens disproportionately affect smaller, independent practices that lack the administrative infrastructure of larger health systems. When physicians must dedicate significant time to navigate insurer requirements, they have less time to focus on patient care, research, and community health initiatives.

Insurance companies play a vital role in the healthcare system, but their administrative practices should support and not hinder care delivery. MSSNY will, together with our allies, continue to advocate for a system in New York that balances insurer oversight with physician autonomy by ensuring fair reimbursement. protecting the doctor-patient relationship, and promoting a healthcare environment that prioritizes access, efficiency, and quality outcomes. Urge your legislators to support prior authorization reform.

As MSSNY President, I am committed to advancing reforms that ensure physicians can spend their energy where it matters most, caring for their patients.

All the best,

Mark J. Adams, MD, MBA, FACR
MSSNY President

Payment & Practice: Turning Complex Payer Challenges Into $38 Million Recovered Revenue

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Key Point: MSSNY’s Payment and Practice team has recovered $38 million since 2021, including $10.8 million so far in 2026, directly returning revenue to physician practices.
Why It Matters: Payer denials, recoupments, and network disputes continue to consume valuable physician time and threaten financial sustainability.
Impact on Practice: Real physician experiences show successful resolution of stalled claims, recovered payments, and prevention of costly recoupments.
What MSSNY is Doing: MSSNY provides hands-on payer advocacy, regulatory expertise, and persistent follow-through on complex claims.

New York physicians are already navigating staffing shortages, regulatory demands, and growing administrative burdens. Payer disputes can be among the most costly and frustrating challenges facing a practice. Denied claims, delayed payments, and unexpected recoupments do more than create paperwork. They threaten financial stability and divert time away from patient care. MSSNY’s Payment and Practice team exists to serve as a direct advocate for physicians when payer challenges become difficult to resolve alone. The results speak clearly. Since 2021, MSSNY’s Payment and Practice team has helped recover $38 million for physician practices across New York, including $10.8 million so far in 2026 alone. These recovered funds represent real revenue returned to practices that might otherwise have been lost—helping physicians maintain operations, retain staff, and continue delivering care to their patients.

Physicians and practice teams across New York consistently share powerful experiences that reflect the real-world impact of this service.

“After an extended and frustrating effort to resolve an insurance network issue on my own, I had nearly exhausted all options without progress. Heather Lopez brought a level of professionalism, persistence, and strategic insight that immediately changed the trajectory. She was able to open doors that had remained closed for a long time and navigated the process with clarity and purpose. Her ability to advocate effectively, while maintaining a thoughtful and composed approach, ultimately led to a successful outcome. What stands out most is her genuine commitment to supporting physicians and her willingness to go the extra mile. I would recommend her without hesitation to anyone dealing with complex payer-related challenges.” — Ankur Shah, MD

“I cannot speak of Heather Lopez highly enough. She has been an exceptional advocate in dealing with health insurance companies—knowledgeable, persistent, and incredibly effective. She is always responsive, truly cares, and consistently goes above and beyond to help. Her guidance and support makes a difficult process much easier.” — David Volpi, MD

“I came across Heather Lopez from a colleague of mine, and I’m truly grateful that I did. Her professionalism and knowledge of billing and ethics are unmatched. She is the true definition of grace. Without the help of her and the MSSNY team, we would be sitting and waiting for IDR money that could never be recovered. With the help of Heather and her team, we have been able to recover monies that were almost near impossible. Not only has she assisted with recovery, but she has been able to stop recoups of payments and retrieve monies on claims that we thought were lost. I give my highest recommendation for anyone who is in a similar situation and is looking for someone to be an advocate for their medical practice; you will not be disappointed. As we continue to work with Heather and MSSNY, I know we will have continued success, and we look forward to building a stronger working relationship in the near future.” — Samantha Romano-Craig, Biller for Dr. Stelios Koutsoumbelis

“Heather consistently demonstrates a high level of professionalism, knowledge, and dedication in her role. Her responsiveness is exceptional—she addresses inquiries promptly and ensures that no issue goes unresolved. What sets her apart is her strong ability to follow up and follow through; once something is placed in her hands, I have complete confidence that it will be handled thoroughly and efficiently. She is an invaluable resource to MSSNY members, including many of my clients, and makes navigating complex matters significantly easier. Working with Heather is seamless as she approaches every situation with both expertise and genuine care, which is evident in the way she advocates for and supports those she works with. Her work ethic, reliability, and commitment to excellence make her a true asset to MSSNY and the physicians it serves.” — Joanna Georgilis, CMOM, CMRS

These experiences reflect a broader truth shared by practices across the state: when payer challenges arise, physicians do not have to face them alone. MSSNY continues to stand alongside New York physicians—protecting their practices, strengthening their financial stability, and advocating for fair reimbursement so physicians can focus on what matters most: delivering care to their patients.

If your practice has unresolved claims, payment disputes, or recoupment concerns, connect with MSSNY’s Payment and Practice team and start recovering what your practice has earned.

Chronic Care Management: Your Practice’s Missing Link in 2026

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Let’s be honest: if you’re running a practice in New York right now, you’re likely feeling the squeeze. You’ve got more patients than ever living with multiple chronic illnesses, a mountain of paperwork, and a reimbursement system that still feels like it’s stuck in the past.

It’s a recipe for burnout, and it leaves a massive gap in care for the people who need it most.

The CCM Opportunity

Medicare introduced Chronic Care Management (CCM) to bridge that gap. The idea is simple: pay providers for the work they’re already doing or want to be doing (between office visits). If a patient has chronic conditions, you can get reimbursed for the coordination, the phone calls, and the check-ins that keep them out of the ER.

Debunking the “Administrative Nightmare” Myth

Most offices see CCM and think: more staff, more clicks, and more headaches. When your team is already stretched thin, adding another layer of documentation feels like a non-starter.

But here’s the shift: when CCM is done right, it isn’t an “extra” task – it’s a clinical framework. It’s about building a team-based rhythm that makes your day-to-day more predictable.

The Power of the “Check-In”

The real magic of CCM happens in the details, particularly with medication management. We all know the reality for patients with multiple conditions: they have a pharmacy’s worth of pill bottles, they’re confused about what does what, and they’re one missed dose away from a hospital stay.

By integrating regular medication reviews into CCM, you aren’t just checking a box for Medicare; you’re literally preventing the complications that clog up your schedule later.

The Big Picture: Better Care, Better Revenue

For Doctors: You get better performance on quality metrics and a clearer picture of your patient’s health.
For Staff: workflows become more structured and less reactive.
For Patients: They feel seen. They know someone is looking out for them, even when they aren’t in the exam room.

How Do You Get Started?

The hurdle isn’t whether CCM is worth it – we know it is. The hurdle is how to do it without breaking your team. Whether you choose to build a dedicated internal team or partner with an organization that provides the infrastructure for you, the goal is to make “comprehensive care” a sustainable reality rather than just a buzzword.

Exclusive for MSSNY Members: ChronicCare understands the specific pressures facing New York physicians. To help you navigate these requirements, they are offering free CCM evaluations for all MSSNY member practices. They will look at your current patient population and workflow to show you exactly how a Chronic Care Management program would look in your office – and what it could do for your bottom line. Contact – Dr. Cedrick Batchateu; ChronicCare; Tel: 914-355-6796 | [email protected]; www.chroniccare.net

Capital Update April 17, 2026

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As State Budget Negotiations Progress, Physicians Must Urge Legislators to Protect Patient Access to Community-Based Physician Care and Treatment

With the State Legislature having passed multiple State Budget extenders until April 20, negotiations are beginning to intensify towards the Senate, Assembly and Governor arriving at an agreement for a State Budget technically due on April 1. Therefore, physicians must continue to advocate to their legislators on the several pressing State Budget health care policy issues under negotiation that will exacerbate the significant challenges facing physician practice across the State if they are adversely decided.

Urge Your Legislators to Reject Steep Increases in Medical Liability Costs.
Both the Senate and Assembly recommended rejection of the Governor’s proposal to impose $40 million in new costs to the 16,000 physicians who receive Excess Medical Malpractice Insurance coverage by requiring them to pay 50% of the coverage cost. This short-sighted proposal will hit physicians with thousands of dollars in additional new costs when they can least absorb it, and New York physicians already pay far and away the highest liability costs in the country.

Please continue to urge your legislators to continue to OPPOSE this measure. Reject Physician Cost-Share.

Urge Your Legislators to Protect Access to a Fair Dispute Resolution Process.
Both the Senate and Assembly recommended rejection of the Governor’s proposal that threatens immediate specialty care availability in Emergency Departments across New York State by upending New York’s innovative IDR payment resolution process for non-participating provider claims, altering the criteria to make it one-sided towards health insurer interests and eliminating ability to appeal out of network Medicaid Managed Care disputes to IDR. Essentially, this would enable the health insurer to “put its thumb on the scale” in what is supposed to be an INDEPENDENT dispute resolution process.

For more information on this issue, please see these op-eds from MSSNY President Dr. Mark Adams PressReader.com and MSSNY Immediate Past-President Dr. David Jakubowicz Newsday.

Please continue to urge your legislators to continue to OPPOSE this measure Protect Fair IDR Process.

Urge Your Legislators to Preserve Physician-Led Team Care.
Both the Senate and Assembly recommended rejection of the Governor’s proposal to permit many Physician Assistants (PAs) to practice without any defined physician supervision after 8,000 hours practice, despite a law implemented last year giving PAs significantly more care responsibilities.

Urge your legislators to continue to OPPOSE this proposal. Preserve Physician-led Care.

Urge Your Legislators to Preserve County Medical Society Peer Review.
The State Assembly recommended rejection of the Governor’s proposal to eliminate the historical vetting role of the county medical society in recommending physicians to participate in the Workers’ Compensation program. Unfortunately, the Senate included this proposal in its one-House Budget proposal as part of a larger reform package that also included measures seeking to reduce some of hassles physicians experience in the WC system.

This proposal would eliminate an important community review role that helps to ensure injured workers are treated by qualified physicians. The problem with Workers’ Compensation is not the application process, but its low payments relative to the enormous hassles of claim submissions and non-payment months and years after providing complex care to injured workers. Please continue to urge your legislators to OPPOSE elimination of the important vetting role of county medical societies. Preserve Workers’ Compensation Peer Review

Urge Your Legislators to Enact Meaningful Reduction in Prior Authorization Hassles.
The Senate included the Executive Budget proposal supported by MSSNY to: prohibit health insurers from requiring a prior authorization more than once per year for treating a chronic health condition; requiring greater transparency of health plan formularies; requiring greater transparency of prior authorization denials; and to provide a 90-day transition period for a patient to continue to be treated by that patient’s physician if the patient changes their health plan coverage.

The Assembly largely included the Governor’s prior authorization proposal but did include some substantive limitations on the “once per year” limitation, permitting plans to impose additional prior authorization requirements based upon “nationally recognized clinical practice guidelines” for evaluating possible side effects from an approved treatment, or substantive changes in nationally recognized treatment guidelines. MSSNY together with several other groups have expressed concerns these additional provisions could undermine the benefit of this “once per year” rule by empowering health plans to continue to impose unreasonable prior authorization requirements.

At the same time, MSSNY continues to urge that the State Budget include far-reaching prior authorization reform legislation (A.3789, Weprin/S.9651, Rivera – before the Senate Health Committee next week) that would reduce the time for receiving prior authorization requests and prohibit altogether repeat prior authorization requirements from health plans. More information here: 2026 Budget Prior Auth Fact Sheet.

Centers for Medicare & Medicaid Services (CMS) Proposes Reforms to Increase Patient Access to Medications, Increase Transparency & Reduce Administrative Burdens

A new, proposed rule from the Centers for Medicare & Medicaid Services (CMS) would require faster prior authorization decisions, expand electronic prior authorization to include prescription drugs, and increase transparency across federal health insurance programs including Medicare Advantage, Medicaid, the Children’s Health Insurance Program (CHIP), Qualified Health Plans (QHP) on the Federally-facilitated Exchanges, and Small Group Market QHPs on the Federally-facilitated Small Business Health Options Program (FF-SHOP).

Building on a 2024 CMS rule, which addressed prior authorization for non-medication healthcare services, this proposal creates a streamlined process for medications as is the case with other covered, non-pharmaceutical services. Specifically, the proposed rule modernizes prior authorization for medications by establishing clear deadlines for insurance company decisions of no later than 24 hours for urgent requests and 72 hours for non-emergencies. The proposed policy would also increase transparency by requiring full disclosure of claims denials and appeals outcomes. The proposal also calls for expansion of electronic prior authorization requirements to include medications.

To read the full statement from CMS: CMS Proposes Major Reforms to Speed Up Patient Access to Drugs, Increase Transparency, and Reduce Administrative Burden | CMS

To view the complete proposed rule on the Federal Register: https://www.federalregister.gov

To view the CMS fact sheet:
https://www.cms.gov/newsroom/fact-sheets/2026-cms-interoperability-standards-prior-authorization-drugs-proposed-rule

Congressional Committee Issues Report Criticizing Medical Residency Programs Across the Country

The US House Judiciary Committee recently released an interim staff report raising significant concerns with the U.S. medical residency market.

Based on a review of more than 1,500 documents and physician interviews, the Committee concluded in its interim report that the National Residency Match Program (NRMP) “constrains competition”. The Committee concluded in its report that these structures significantly limit residents’ basic employment rights. Examples identified include applicants being prohibited from securing binding pre‑Match commitments, and those who decline an assigned placement risk being labeled “Match violators.” Employment terms are offered on a take‑it‑or‑leave‑it basis, with little transparency or opportunity for negotiation. Even unmatched applicants remain subject to NRMP control through the Supplemental Offer and Acceptance Program (SOAP).

Based on these findings, the Committee identified several areas for possible future congressional action, including reconsideration of the NRMP’s 2004 antitrust exemption, increasing competition and flexibility in residency recruitment, and closer scrutiny of centralized wage‑setting and limits on bargaining rights. The report frames residency hiring reform as a necessary component of addressing physician shortages and safeguarding patient access to care.

Because of its importance to the physicians of our future, MSSNY will continue to monitor developments on this investigation and possible legislation.

MSSNY Councilor Dr Stacey Watt Honored with Lifetime Achievement Award

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MSSNY proudly recognizes Dr. Stacey Watt, a member since 2013, who has been honored with a Lifetime Achievement Award at the 2026 Excellence in Health Care Awards. This prestigious recognition celebrates physicians and health care leaders whose careers have made a sustained and meaningful difference in patient care and the broader health care landscape. Dr. Watt’s professional journey reflects a deep commitment to service, education, and leadership within organized medicine and academic medicine.

Dr. Watt currently serves as President of the Malignant Hyperthermia Association of the United States and is a Professor of Anesthesiology at the University at Buffalo Jacobs School of Medicine & Biomedical Sciences. Her leadership extends beyond clinical practice into organized medicine, where she has served as Past President of the Medical Society of the County of Erie, a Councilor to the Medical Society of the State of New York, and as a leader within statewide physician organizations. Through these roles, she has helped advance physician advocacy, professional collaboration, and patient safety initiatives across New York.

The Excellence in Health Care Awards honor physicians, nurses, administrators, and other professionals whose work improves the delivery of care across hospitals, clinics, and community-based organizations. Dr. Watt’s recognition among this distinguished group reflects the importance of physician leadership not only in clinical settings but also in shaping policy, education, and patient safety efforts that benefit entire communities.