86% of claim denials are avoidable, yet providers spend $19.7B annually fighting policy-related denials. Learn how to build a robust payer policy database that tracks frequent policy changes, enables real-time claim validation, and reduces denials. Get step-by-step implementation strategies, team structure blueprints, technology integration guides, and proven tactics to achieve 95% policy compliance and same-day policy updates.

Clinical Documentation Improvement teams have mastered denial prevention through real-time collaboration and concurrent review. Discover how to transform your denial management program using CDI best practices: pre-submission audits, physician query protocols, cross-functional teams, and predictive analytics. Get actionable strategies to prevent documentation-driven denials, improve appeal overturn rates, and reduce administrative costs.

Stop losing revenue to inpatient vs. observation status denials. AI-powered utilization review helps hospitals correctly classify patients, reduce claim denials, and cut appeal time from hours to minutes. Learn implementation strategies, key performance metrics, and how leading healthcare organizations use AI to strengthen UR processes, improve documentation, and recover more revenue through successful appeals.

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

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

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

Introduction Recent data from the American Hospital Association reveals that between 2022 and 2023, Medicare Advantage claim denials increased by a staggering 55.7%, representing billions in contested revenue for U.S. hospitals (AHA, September 2024) . With hospital operating margins hovering at just 2.5%, DRG downgrades represent a significant threat to financial sustainability. This guide provides hospital administrators with a practical, step-by-step approach to identify, p

Hospitals lose $19.7B annually fighting denials, yet 54% get overturned on appeal. This guide shows how AI automation reduces appeal time from 4 hours to 15 minutes while increasing success rates. Start reclaiming your revenue today. Nearly 15% of all medical claims submitted to private payers and approximately 16% of Medicare Advantage claims were initially denied in 2024, with inpatient care facing an even higher denial rate of 14.07% ( Premier Inc., February 2024 ). This c

ProPublica reveals how EviCore uses AI to deny healthcare claims, transforming patient restrictions into profits.