The winter months are historically the slowest time for medical billing. Deductibles reset on January 1, flooding insurers with paperwork. Staffing shortages due to the flu season slow down administrative offices. But in 2026, structural changes to the insurance system have added new bottlenecks. New federal pilot programs and AI-driven audit tools are flagging millions of legitimate claims for manual review.
Patients accustomed to two-week turnaround times are now waiting months for an Explanation of Benefits. This delay often leaves families unsure of their final financial responsibility. Until the claim processes, you cannot pay the bill or appeal the denial. Here are the seven specific medical claims facing the longest delays this winter.
1. Chronic Condition Prior Authorizations
A new federal pilot is slowing down routine approvals. The Medicare WISeR model launched in six states this January. It uses AI to flag “wasteful” services for manual review. Claims for nerve stimulators or knee replacements in states like Ohio and Texas are getting stuck. Human reviewers must now double-check the AI’s flag before payment release. This adds weeks to the processing time for previously routine maintenance care.
2. Durable Medical Equipment (DME)
Getting a CPAP machine or glucose monitor is administratively harder this year. New competitive bidding rules have disrupted the vendor lists for 2026. Insurers are manually verifying that your supplier is still contractually approved. If you used a supplier that lost their bid, the claim enters a “pricing hold.” The insurer must determine the out-of-network reimbursement rate manually. This affects thousands of seniors needing oxygen supplies this winter.
3. Out-of-Network Emergency Bills
The backlog for dispute resolution is still massive. The No Surprises Act protects you from balance billing. However, the arbitration process between insurers and hospitals is clogged. There are over 300,000 disputes currently pending federal adjudication. If you visited an ER this winter, your claim might sit in “pending” status for six months. You generally do not owe payment until this dispute is officially resolved.
4. Hospital-at-Home Admissions
Care in your living room causes billing confusion. The waiver for Acute Hospital Care at Home was extended through 2026. However, many insurers have not updated their automated claims software. These claims look like “inpatient” codes but occur in a “home” location. This mismatch triggers an automatic rejection in many systems. A human coder must intervene to override the error and process the claim.
5. Major Academic Hospital Visits
Network disputes are creating manual work. Systems like Mayo Clinic and Mass General dropped major Medicare Advantage plans this year. Patients who still visited these facilities are generating “out-of-network” claims. These cannot be auto-adjudicated like in-network claims. Each bill requires a claims adjuster to calculate the “allowed amount” based on local rates. This manual pricing takes three times longer than standard processing.
6. Multi-Virus Respiratory Panels
Testing for everything at once triggers audits. Labs are running “quad-panels” for Flu, RSV, Covid, and Strep. Insurers are aggressively auditing these expensive combo tests for medical necessity. They want proof you had symptoms justifying all four tests. If the doctor’s notes are vague, the claim stops. The insurer sends a request for medical records. The claim sits unpaid until the doctor’s office faxes the proof.
7. Mental Health Telehealth Prescriptions
Online prescribing is under the microscope. Federal regulators are scrutinizing telehealth platforms for over-prescribing ADHD medications. Insurers have responded by pausing claims from certain high-volume digital providers. They are auditing the duration of the video visits. They verify a real patient-doctor relationship existed. Your therapy claim may be held for 45 days while this audit is completed.
Monitor Your “Pending” Tab
Do not ignore a claim that stays “pending” for more than 30 days. Log in to your insurance portal weekly. If a claim stalls, call your provider’s billing office. Ask if they have received a request for medical records. Often, the delay is a simple missing document that you can help expedite.
Has your winter flu test been stuck in “processing” for weeks? Leave a comment below—share your wait times with other readers!
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