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

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

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