Denials are growing faster than most RCM teams can respond. Payers are scaling AI-powered reviews across evolving policy frameworks. Yet many hospitals are still fighting them manually. This is beyond being inefficient. It's ultimately unsustainable. When payers can deny in seconds but your team needs days to appeal, you're fighting an uphill battle and leaving revenue on the table. We analyzed countless successful complex denial overturns across top payers (Aetna, Anthem, Un

A federal court just blocked CMS's plan to use statistical extrapolation  in Risk Adjustment Data Validation (RADV) audits. MA plans may be celebrating but if you're a provider, here's what you need to understand: The burden of documentation falls on you either way. Whether CMS is using extrapolation or not, your documentation is the foundation of every audit. When payers first review your records, your job is to prove that every diagnosis and procedure was supported by clear

Healthcare claim denials reached an alarming 15% of all claims submitted to private payers in 2024, with providers spending an estimated...

Healthcare organizations are facing an unprecedented surge in claim denials, with 77% of providers reporting increased denial rates from...

Stepping into the role of Vice President of Patient Financial Services (PFS) at a large, complex health system marks a pivotal point in...

Observations from the conference floor, minus the vendor hype

The Sepsis Denial Crisis in Hospital Revenue Cycles Sepsis-related DRG downgrades are among the most financially damaging and preventable forms of revenue leakage hospitals face. When payers retrospectively challenge sepsis diagnoses and downgrade them to simple infections or pneumonia, the financial hit is immediate: $3,000 to $7,000 lost per case, and over $15,000 for more complex claims. But the impact goes deeper. These downgrades reduce your Case Mix Index (CMI), lowerin

The Problem Every month, physicians deliver complex, ongoing care to ESRD patients. But even when that care is delivered correctly, it...

Preparing for the New Era of AI-Powered Audits The Landscape is Changing – Are You Ready? DRG downgrades are on the rise. Medicare...

Nearly 15% of all healthcare claims submitted to payers for reimbursement are initially denied, with more than half eventually overturned...

Nearly three in four healthcare providers report that insurance claim denials have increased between 2022 and 2024, with approximately 38% of survey respondents indicating that at least one in ten claims are denied ( Experian Health, 2024 ). Among these denials, those based on medical necessity represent a significant and persistent challenge for healthcare organizations, adding administrative burden and threatening financial stability. Understanding Medical Necessity Denials

Connecting Innovation with Opportunity At Cofactor, we're passionate about building bridges between innovative healthcare startups and the resources they need to thrive. Our recent Healthcare Demo Day exemplified this mission, bringing together nine remarkable companies working to transform healthcare delivery, diagnostics, treatment, and patient experience. What makes Chicago’s healthcare innovation scene so unique is the intersection of world-class hospitals, top research i

Healthcare providers are experiencing increasing financial pressure, with PwC projecting an 8% year-on-year medical cost trend in 2025 for the Group market, driven by inflationary pressure, prescription drug spending, and behavioral health utilization ( PwC, February 2025 ). Meanwhile, mergers and acquisitions in the healthcare sector demonstrated continued resilience in 2024 despite a 9% decline in deal volume from 2023 ( Fierce Healthcare, January 2025 ). In this complex fi

According to recent data, Recovery Audit Contractors (RACs) recovered over $2 billion in improper payments in FY 2021 alone, creating a significant financial burden for healthcare providers already operating on thin margins ( Auditec Solutions, 2024 ). What makes these audits particularly challenging is their post-payment nature—they target revenue that has already been accounted for and often spent, forcing hospitals to unexpectedly return funds they believed were secured. I

When "Prior Processing Information Appears Incorrect" Costs You Money Let's face it - pediatric immunization billing is tricky. At the heart of this challenge is the critical relationship between three key elements: CPT® code 90460 (immunization administration with counseling), ICD-10 code Z23 (encounter for immunization), and the dreaded CARC 129 denial (prior processing information appears incorrect). When these three components don't work together properly, your revenue ta

Chicago has emerged as a vibrant nerve center for healthcare technology innovation, with a thriving ecosystem of startups tackling some of the industry's most pressing challenges. As healthcare continues to undergo rapid digital transformation, our city is positioning itself at the forefront of developing solutions that improve access, quality, and efficiency of care. We organized our Healthcare Demo Day to spotlight this incredible local talent and create meaningful connecti

According to Experian Health's 2024 State of Claims report , a staggering 73% of healthcare providers report that claim denials are increasing, while 67% feel it's taking longer to get paid. These rising denial rates represent a significant financial challenge, with hospitals spending an estimated $19.7 billion in 2022 trying to overturn denied claims, according to the American Hospital Association . For hospital administrators, developing a strategic approach to appealing in