# Claim Denials * **Definition:** Claim denials refer to the rejection of a healthcare provider's request for payment from an insurance company for services rendered to a patient. This can occur due to various reasons such as incorrect coding, lack of medical necessity, or failure to obtain prior authorization. * **Taxonomy:** Healthcare Topics / Claim Denials ## News * Selected news on the topic of **Claim Denials**, for healthcare technology leaders * 1.7K news items are in the system for this topic * Posts have been filtered for tech and healthcare-related keywords | Date | Title | Source | | --- | --- | --- | | 5/23/2025 | [**WorkDone Secures $1.8M to Tackle EHR Documentation Errors with AI Copilot**](https://hitconsultant.net/2025/05/23/workdone-secures-1-8m-to-tackle-ehr-documentation-errors-with-ai-copilot/) | [[HIT Consultant]] | | 5/19/2025 | [**How Smarter AI Strikes Back for Hospitals**](https://medcitynews.com/2025/05/how-smarter-ai-strikes-back-for-hospitals/) | [[MedCity News]] | | 5/7/2025 | [**Pairing Predictive and Generative AI to Accelerate Efficiency and Improve Outcomes in Healthcare**](https://www.beckershospitalreview.com/healthcare-information-technology/innovation/pairing-predictive-and-generative-ai-to-accelerate-efficiency-and-improve-outcomes-in-healthcare/) | [[Beckers Hospital Review]] | | 4/24/2025 | [**CHS emphasizes divestitures, strong volumes in Q1 earnings - Healthcare Dive**](https://www.healthcaredive.com/news/chs-community-health-systems-q1-2025-earnings-divestitures-strong-volumes/746222/) | [[Healthcare Dive]] | | 4/7/2025 | [**AI helps reduce billing errors, but integration challenges loom - Healthcare IT News**](https://www.healthcareitnews.com/news/ai-helps-reduce-billing-errors-integration-challenges-loom) | [[Healthcare IT News]] | | 4/3/2025 | [**IKS Health Handles the Tasks Clinicians Get “Stuck With”**](https://www.healthcareittoday.com/2025/04/03/iks-health-handles-the-tasks-clinicians-get-stuck-with/) | [[Healthcare IT Today]] | | 3/10/2025 | [**Northwell CFO: Revenue cycle optimization critical as system grows**](https://www.beckershospitalreview.com/finance/northwell-cfo-revenue-cycle-optimization-critical-as-system-grows.html) | [[Beckers Hospital Review]] | | 2/25/2025 | [**How Insurance Claim Denials Harm Patients' Health, Finances**](https://www.ajmc.com/view/how-insurance-claim-denials-harm-patients-health-finances) | [[AJMC]] | | 2/18/2025 | [**Iodine Software Launches Appeals Management Workspace**](https://hitconsultant.net/2025/02/18/iodine-software-launches-appeals-management-workspace/) | [[HIT Consultant]] | | 1/31/2025 | [**Arcadia Named #1 in Healthcare Data Governance and Analytics in the 2025 Black Book ...**](https://finance.yahoo.com/news/arcadia-named-1-healthcare-data-183000182.html) | [[Yahoo Finance]] | | 1/17/2025 | [**8 Way AI Can Optimize Revenue Cycle Management in 2025**](https://hitconsultant.net/2025/01/17/8-way-ai-can-optimizing-revenue-cycle-management-in-2025/) | [[HIT Consultant]] | | 1/2/2025 | [**XpertDox and Nao Medical Announce Partnership to Transform Revenue Cycle ... - PR Newswire**](https://www.prnewswire.com/news-releases/xpertdox-and-nao-medical-announce-partnership-to-transform-revenue-cycle-and-improve-clinical-documentation-through-ai-driven-innovation-302340717.html) | [[PR Newswire]] | | 12/9/2024 | [**Medical Billing Challenges: How Healthcare AI Helps Navigate Claim Denials**](https://www.healthitanswers.net/medical-billing-challenges-how-healthcare-ai-helps-navigate-claim-denials/) | [[Health IT Answers]] | | 11/19/2024 | [**Thoughtful AI Transforms Healthcare RCM With Comprehensive Team of Specialized AI Agents**](https://www.businesswire.com/news/home/20241119829963/en/Thoughtful-AI-Transforms-Healthcare-RCM-With-Comprehensive-Team-of-Specialized-AI-Agents) | [[Business Wire]] | | 11/19/2024 | [**Thoughtful AI Transforms Healthcare RCM With Comprehensive Team of Specialized AI Agents**](http://www.businesswire.com/news/home/20241119829963/en/Thoughtful-AI-Transforms-Healthcare-RCM-With-Comprehensive-Team-of-Specialized-AI-Agents/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 11/19/2024 | [**Thoughtful AI Transforms Healthcare RCM With Comprehensive Team of Specialized AI Agents**](http://www.businesswire.com/news/home/20241119829963/en/Thoughtful-AI-Transforms-Healthcare-RCM-With-Comprehensive-Team-of-Specialized-AI-Agents/?feedref=JjAwJuNHiystnCoBq_hl-Q-tiwWZwkcswR1UZtV7eGe24xL9TZOyQUMS3J72mJlQ7fxFuNFTHSunhvli30RlBNXya2izy9YOgHlBiZQk2LOzmn6JePCpHPCiYGaEx4DL1Rq8pNwkf3AarimpDzQGuQ==) | [[Business Wire]] | | 11/12/2024 | [**Aspirion Appoints Nick Giannasi as Chief Executive Officer - PR Newswire**](https://www.prnewswire.com/news-releases/aspirion-appoints-nick-giannasi-as-chief-executive-officer-302301945.html) | [[PR Newswire]] | | 11/6/2024 | [**Q/A: Vim CEO Talks Solving the Rising Tide of Healthcare Claim Denials - HIT Consultant**](https://hitconsultant.net/2024/11/06/vim-ceo-talks-solving-the-rising-tide-of-healthcare-claim-denials/) | [[HIT Consultant]] | | 10/17/2024 | [**Healthcare Payer Services Business Research Report 2023-2024 & 2030 - Growth in Telehealth and Virtual Care Services Expands the Scope of Payer Services - ResearchAndMarkets.com**](http://www.businesswire.com/news/home/20241017425707/en/Healthcare-Payer-Services-Business-Research-Report-2023-2024-2030---Growth-in-Telehealth-and-Virtual-Care-Services-Expands-the-Scope-of-Payer-Services---ResearchAndMarkets.com/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 10/17/2024 | [**Healthcare Payer Services Business Research Report 2023-2024 & 2030 - Growth in Telehealth and Virtual Care Services Expands the Scope of Payer Services - ResearchAndMarkets.com**](http://www.businesswire.com/news/home/20241017425707/en/Healthcare-Payer-Services-Business-Research-Report-2023-2024-2030---Growth-in-Telehealth-and-Virtual-Care-Services-Expands-the-Scope-of-Payer-Services---ResearchAndMarkets.com/?feedref=JjAwJuNHiystnCoBq_hl-Q-tiwWZwkcswR1UZtV7eGe24xL9TZOyQUMS3J72mJlQ7fxFuNFTHSunhvli30RlBNXya2izy9YOgHlBiZQk2LOzmn6JePCpHPCiYGaEx4DL1Rq8pNwkf3AarimpDzQGuQ==) | [[Business Wire]] | | 10/15/2024 | [**Apprio Announces Smart Solution To Pro-Actively Reduce Claim Denials - Yahoo Finance**](https://finance.yahoo.com/news/apprio-announces-smart-solution-pro-131500991.html) | [[Yahoo Finance]] | | 10/15/2024 | [**Healthcare EDI Market to Hit USD 7.11 Billion by 2029 with 9.7AGR - PR Newswire**](https://www.prnewswire.com/news-releases/healthcare-edi-market-to-hit-usd-7-11-billion-by-2029-with-9-7-cagr--marketsandmarkets-302276018.html) | [[PR Newswire]] | | 10/10/2024 | [**Healthcare Payer Services Business Research Report 2024: Global Market to Surpass $100 ...**](https://finance.yahoo.com/news/healthcare-payer-services-business-research-141400536.html) | [[Yahoo Finance]] | | 7/16/2024 | [**United States Healthcare BPO Market Advancements Highlighted by Report Analysis, Size ...**](https://www.whatech.com/og/markets-research/medical/857204-united-states-healthcare-bpo-market-report-analysis-size-share-2024-32) | whatech.com | | 6/17/2024 | [**Healthcare BPO Market Anticipates USD 626.6 Billion by 2029 with 9.7% CAGR - MarketsandMarketstm**](https://www.lelezard.com/en/news-21422134.html) | lelezard.com | ## Topic Overview (Some LLM-derived content — please confirm with above primary sources) ### Key Players - **Experian Health**: A company that has introduced new revenue cycle products to address the rising issue of claim denials. - **Apprio**: Introduced the Intelligent Denial Prevention™ solution to help healthcare providers reduce claim denials through advanced automation and AI. - **Delta Dental of Washington**: A healthcare benefit manager fined for improper claim denials and violations of state insurance laws. - **Vim**: A company that supports healthcare providers in addressing challenges related to claim denials and prior authorization requirements. - **UnitedHealth Group**: A major health insurer involved in a class action lawsuit regarding the use of AI in claim denials. - **Thoughtful AI**: A company that has launched AI Agents to automate revenue cycle management processes, significantly reducing claim denials. - **FinThrive**: A technology partner chosen by the Pennsylvania Mountain Healthcare Alliance for end-to-end revenue cycle management to address claim denials. - **Accuity**: A leader in clinical revenue cycle integrity, providing AI-driven solutions to enhance clinical documentation and coding compliance, resulting in low denial rates. - **Sohar Health**: AI-driven provider focused on eligibility determination and verification of benefits to reduce claim denials. - **Wyssta**: Claims administration manager linked to increased complaints and violations at Delta Dental. - **Iodine Software**: Offers solutions like the Appeals Management Workspace and Clinical Intelligence Platform to automate denial management and improve documentation accuracy. - **Premier Inc.**: Analyzes healthcare spending on claims adjudication and advocates for reforms in prior authorization processes. - **Sunknowledge Inc.**: Medical billing provider specializing in prior authorization and claims management. - **Solventum**: A company that has introduced an AI-driven payment integrity and revenue cycle solution to help healthcare systems reduce and prevent claim denials. - **Athenahealth**: A healthcare technology company transforming revenue cycle management through AI-driven solutions, achieving significant reductions in claim denials and administrative burdens. - **XpertDox**: A company integrating AI medical coding software into revenue cycle management to enhance clinical documentation and reduce claim denials. - **Sunknowledge Services Inc.**: A provider of prior authorization services with a high approval rate, streamlining the process to reduce delays in patient treatment. - **Sift Healthcare**: A partner of Solventum, aiming to transform denial prevention strategies in healthcare revenue cycles. ### Partnerships and Collaborations - **Solventum and Sift Healthcare**: Collaborating to shift from reactive to proactive strategies in managing healthcare revenue cycles and claim denials. - **FinThrive and Pennsylvania Mountain Healthcare Alliance**: Collaboration to implement a revenue management system aimed at improving financial performance and addressing claim denials. - **Xsolis and Beacon Health System**: Collaboration to improve claims management and operational efficiency through AI solutions. - **XpertDox and Nao Medical**: Collaboration to integrate AI medical coding software into revenue cycle management operations, resulting in improved charge capture and reduced claim denials. - **Sohar Health and Kindred Capital**: Funding partnership to enhance eligibility determination and verification processes. - **Tanner Health and Corti**: A strategic partnership aimed at enhancing healthcare operations through AI-driven medical coding solutions. - **VoiceCare AI and Caduceus Capital Partners**: Funding partnership to enhance healthcare administration through AI technology. - **PayrHealth and SlicedHealth**: Strategic partnership to provide advanced contract modeling and revenue optimization tools to healthcare providers. - **Aspirion**: Appointed Nick Giannasi as CEO to enhance leadership in healthcare technology and revenue cycle management. ### Innovations, Trends, and Initiatives - **AI in Claims Processing**: AI is being increasingly utilized by both payers and providers to enhance claims processing efficiency, leading to a rise in claims denials. - **Fight Health Insurance**: An AI tool designed to help consumers navigate the appeal process for claim denials, gaining popularity on social media. - **Predictive Analytics**: Utilized to forecast potential claim denials and facilitate proactive resource allocation, minimizing delays in reimbursements. - **Apprio IDP**: A new solution designed to help healthcare providers reduce claim denials through automation and AI tools. - **Healthcare Information Exchange (HIE)**: Emerging as a crucial trend in denial management, facilitating real-time patient data sharing to enhance claim accuracy. - **AI and Machine Learning Integration**: Healthcare providers are increasingly adopting AI and machine learning to enhance efficiency in revenue cycle management, particularly in addressing claim denials. - **AI in Revenue Cycle Management**: AI technologies are being adopted to automate tasks, improve coding accuracy, and predict denials. - **Black Book Research Report**: A report highlighting the effectiveness of AI in reducing claim denials and establishing KPIs for measuring AI impact in revenue cycle management. - **Pegasus Legal Capital Initiative**: A funding initiative to support patients facing unjust claim denials, ensuring access to necessary medical treatments. - **Automated Pre-Service Financial Clearance**: AI-driven innovation aimed at enhancing revenue accuracy and reducing reimbursement issues. - **Advanced Eligibility Verification Software**: Emerging technology solutions are streamlining the enrollment and benefits verification process, offering real-time eligibility checks to reduce administrative burdens. - **Generative AI (GenAI)**: Emerging tool in healthcare technology to streamline documentation and improve communication in claims processing. - **Generative AI**: Expected to revolutionize RCM by automating processes such as patient eligibility insights, billing coding, and appeals management, thereby reducing costs and improving efficiency. - **Healthcare EDI Market Growth**: The healthcare EDI market is projected to grow significantly, driven by increased claims submissions and regulatory mandates. - **Automation and Machine Learning**: These technologies are being adopted to streamline payment processes, reduce errors, and enhance financial management in healthcare. - **Healthcare BPO Market Growth**: Projected to grow significantly, driven by the need for outsourcing non-core functions to improve efficiency and reduce costs. ### Challenges and Concerns - **Increasing Claim Denials**: Claim denials have risen significantly, costing hospitals approximately $20 billion annually, with denial rates ranging from 17% to over 30% depending on the insurer. - **Rising Claim Denials**: Healthcare providers are facing a significant increase in claim denials, with a reported 20.2% rise in commercial care denials and 55.7% in Medicare Advantage denials. - **Rising Claim Denial Rates**: Healthcare organizations are facing increased claim denial rates, which complicate revenue cycle management and lead to revenue loss. - **Administrative Costs**: Healthcare providers spent $25.7 billion contesting claims denials in 2023, with an average cost of over $57 per claim. - **Financial Burden**: Healthcare systems spend approximately $19.7 billion annually to address denied claims, with 15% of all claims submitted to private payers being initially denied. - **Staffing Shortages**: Ongoing staffing shortages in healthcare are exacerbating the challenges associated with managing claim denials and revenue cycles. - **Patient Awareness**: Many patients are unaware of their rights to appeal denied claims, leading to delays in care and worse health outcomes. - **Administrative Burdens**: Denials disrupt payment processes, consume staff resources, and negatively impact patient experiences, necessitating innovative solutions to manage these challenges. - **Complexity of Claims Processing**: Prior authorization requirements complicate the claims process, affecting reimbursement rates. - **Lack of Transparency in AI Systems**: Hospitals face challenges due to the opacity of AI systems used by payers, complicating the appeals process for denied claims. - **Cybersecurity Threats**: Cybersecurity threats complicate claims processing, contributing to cash flow challenges for healthcare providers. - **AI Error Rates**: Concerns about the use of AI in claim evaluations, with reports of high error rates leading to harmful health outcomes. ## Related Topics [[Claims Denials]]; [[Claims Reviews]]