The Queue of People Who Knew There Was a Queue

Patience Redfield is a prior-authorization appeals coordinator in Texas, one of six states where CMS launched the WISeR prior-authorization model in January 2026.¹ She has worked in appeals coordination for eleven years. Her professional life is measured in dated artifacts: denial letters, appeal submissions, reversal decisions, and the intervals between them. She does not exist. That may be the most realistic thing about her. The people who do this work are largely invisible to the systems they navigate. We spoke with her on a Tuesday afternoon, between a 48-hour follow-up call and a peer-to-peer review she'd scheduled for Wednesday morning.

You've been doing this work for over a decade. What does a given day actually consist of?

Patience: Dates. I manage dates. People assume I manage medical cases, and I suppose I do, in the way a traffic cop manages urban planning. But the raw material of my day is the distance between two timestamps. The denial has a date. My appeal submission has a date. The reversal, if it comes, has a date. Everything I do lives in the gap between those dates.² Making that gap smaller is the job. Documenting what happened inside the gap when it wasn't small enough is also the job. Those are two different jobs, by the way. I get paid for one of them.

The OIG report from June found that Medicare Advantage organizations overturned 95 percent of appealed SNF denials.³ Does that number surprise you?

Patience: Not even a little. But I want to be careful about what it means, because I think people hear "95 percent" and conclude the system works fine, you just have to appeal. And look, it's true that if you appeal, you will probably win. But the OIG itself couldn't fully untangle how much of that overturn rate reflects plans reversing decisions that should never have been denied versus plans approving because more complete documentation came in on the appeal.³ My queue has both kinds. I can't always tell which is which until after the fact. Sometimes not even then.

What does the timeline look like for the people who do appeal?

Patience: The OIG found that MAOs typically approved initial SNF admission requests the same day they were made. Same day. But for enrollees who appealed a denial, the median time from initial request to appeal decision was six days, and 17 percent waited ten days or more.³ That's the arithmetic I live inside. An authorization that would have been granted the same day instead costs the patient six days in a hospital bed. Not because they need to be in a hospital, but because the appeal hasn't cleared yet. They're in the wrong care setting, waiting for a piece of paper that says they can be in the right one.

And when the reversal finally comes?

Patience: It doesn't undo the six days. That's what people miss. The reversal is a dated artifact. It says "approved" on a specific date. But the patient spent six days in a hospital bed accumulating risks that belong to that setting while missing the rehabilitative care a SNF provides.⁴ A hospital is not a holding pen. It has its own dangers. Falls, infections, deconditioning.

It just closes the file.

Only 18 percent of SNF denials were appealed.³ What happens to the other 82 percent?

Patience: They're not in my queue. I want to say that plainly, because it's the most important thing about my job. I only see the people who made it to me. The AMA found that fewer than one in five physicians always appeal a denial. Sixty-two percent said they don't believe the appeal will succeed. Forty-eight percent said patient care can't wait.⁵ From the patient side, KFF found that half of insured adults find some aspect of insurance difficult to understand, and that jumps to eight in ten among people who've had a claim denied.⁵

The OIG noted that nursing home residents faced a 40 percent denial rate, compared to 11 percent for other enrollees.³

Patience: Yeah. And those are the people with the least capacity to navigate any of this. A nursing home resident who gets denied SNF-level care... their care is their current address. They're not a post-surgical patient with a spouse who can make phone calls and send faxes and spend forty minutes on hold with a plan's clinical review department. The population facing the highest denial rate has the fewest resources to fight it. That's not a coincidence and it's not an accident. I don't know what it is, exactly, but it's not those things.

You're in Texas, one of the WISeR states. How has that changed your work since January?

Patience: It added a second clock. WISeR requires prior authorization for thirteen service categories: epidural steroid injections, cervical fusion, skin substitutes, others. If the request goes through the WISeR participant's electronic portal, there's a 72-hour turnaround requirement.¹ But if the request routes through a MAC first, there's no specified turnaround for that handoff.⁶ So my queue now has two populations: portal-routed cases ticking down from 72 hours, and MAC-routed cases on whatever clock they end up on. I don't always know which clock governs a given case until I confirm the routing, which itself takes time, which is its own small comedy.

Are you seeing patterns in WISeR outcomes?

Patience: I can't answer that, and I want to be honest about why. There's no published outcome data. No denial rates, no appeal rates, no reversal rates for WISeR cases.¹ I know the machinery. I know that non-affirmation decisions require a licensed clinician's review before they're issued.⁷ I know that providers can resubmit unlimited times and request peer-to-peer review, which runs on a different track from the standard Medicare appeals process.¹ But I can observe the gears without being able to report the output. Nobody's published that yet. When they do, I'll be very interested, and probably not surprised.

One last question. Your name is Patience.

Patience: My mother either had a sense of humor or a sense of prophecy. Eleven years in, I still haven't figured out which. In this work, patience is simultaneously the one thing you need and the one thing the clinical situation forbids. The patient needs a SNF bed today. The appeal takes six days. My name is the job description and the punchline, and they arrive on the same date.

The OIG's June 2026 report also found that naviHealth, a single contractor, processed half of all SNF admission requests and denied 14 percent, a rate higher than MAOs processing requests internally (11 percent) or through other contractors (9 percent). When enrollees appealed naviHealth denials, MAOs overturned 97 percent.³ One large health plan received 42 percent of all SNF appeals and overturned 99.7 percent of them.³ The entity that issues the denial and the entity that reviews the appeal are often different organizational actors. Patience Redfield navigates this daily, in a queue made of dates and the distances between them.

Footnotes

1. CMS, WISeR Model FAQ. The model launched January 15, 2026, covering six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. ↩ ↩² ↩³ ↩⁴

2. Pharmbills, "The Ultimate Step-By-Step Guide to Prior Authorization" — operational guidance on documentation practices. ↩

3. HHS OIG, "Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission", June 11, 2026. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷

4. PMC, "Extended Hospital Stays in Medicare Advantage and Traditional Medicare" — peer-reviewed research on discharge barriers. ↩

5. AMA, "Over 80% of prior auth appeals succeed. Why aren't there more?", October 2024; includes KFF survey analysis. ↩ ↩²

6. Congressional Research Service, "Overview of the Medicare WISeR Model". ↩

7. ASRA, "CMS Provides More Details on WISeR Prior Authorization Model", October 2025. ↩