# Claims Denials * **Definition:** Claims denials refer to the rejection of a healthcare provider's request for payment from an insurance company for services rendered to a patient, often due to issues such as lack of coverage, incorrect coding, or failure to meet policy requirements. * **Taxonomy:** Healthcare Topics / Claims Denials ## News * Selected news on the topic of **Claims Denials**, for healthcare technology leaders * 1.6K news items are in the system for this topic * Posts have been filtered for tech and healthcare-related keywords | Date | Title | Source | | --- | --- | --- | | 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]] | | 3/31/2025 | [**With RCM Staff in Short Supply, Is AI the Missing Piece? - HIT Consultant**](https://hitconsultant.net/2025/03/31/with-rcm-staff-in-short-supply-is-ai-the-missing-piece/) | [[HIT Consultant]] | | 3/26/2025 | [**Epic Veterans Launch ProsperityEHR to Tackle Behavioral Health's Financial Crisis**](https://hitconsultant.net/2025/03/26/epic-veterans-launch-prosperityehr-to-tackle-behavioral-healths-financial-crisis/) | [[HIT Consultant]] | | 3/25/2025 | [**ProsperityEHR Debuts Next-Gen EHR to Keep Behavioral Health Practices Thriving**](https://finance.yahoo.com/news/prosperityehr-debuts-next-gen-ehr-160000941.html) | [[Yahoo Finance]] | | 3/24/2025 | [**Realizing AI's potential: 5 considerations for assessing AI-powered clinical tools**](https://www.beckershospitalreview.com/innovation/realizing-ais-potential-5-considerations-for-assessing-ai-powered-clinical-tools/) | [[Beckers Hospital Review]] | | 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]] | | 2/26/2025 | [**Providers 'wasted' almost $18B in 2023 overturning claims denials - Fierce Healthcare**](https://www.fiercehealthcare.com/providers/providers-potentially-wasted-almost-18b-2023-overturning-claims-denials-premier-estimates) | [[FierceHealthcare]] | | 2/20/2025 | [**US Hospitals On Track To Exceed Critical Capacity By 2032, Study Shows**](https://kffhealthnews.org/morning-breakout/study-shows-us-hospitals-on-track-to-exceed-critical-capacity-by-2032/) | [[KFF Health News]] | | 1/29/2025 | [**LLMs in Healthcare: A Measured Path to Impact**](https://www.healthcareittoday.com/2025/01/29/llms-in-healthcare-a-measured-path-to-impact/) | [[Healthcare IT Today]] | | 1/29/2025 | [**U.S. Revenue Cycle Management Market Insights, 2024 and 2025-2030 with Change Healthcare, Epic Systems, Experian, McKesson, Oracle, R1 RCM, Veradigm, and SSI Dominating - ResearchAndMarkets.com**](http://www.businesswire.com/news/home/20250129051735/en/U.S.-Revenue-Cycle-Management-Market-Insights-2024-and-2025-2030-with-Change-Healthcare-Epic-Systems-Experian-McKesson-Oracle-R1-RCM-Veradigm-and-SSI-Dominating---ResearchAndMarkets.com/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 12/10/2024 | [**4 Cornerstones for Successful AI Implementation in Hospital Revenue Cycle Management in 2025**](https://hitconsultant.net/2024/12/10/4-cornerstones-for-successful-ai-implementation-in-hospital-revenue-cycle-management/) | [[HIT Consultant]] | | 11/25/2024 | [**Cofactor AI Nabs $4M to Combat Hospital Claim Denials with AI**](https://hitconsultant.net/2024/11/25/cofactor-ai-launches-platform-to-help-hospitals-fight-tidal-wave-of-claims-denials-and-announces-4-million-seed-round/) | [[HIT Consultant]] | | 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]] | | 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 | [**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]] | | 10/13/2024 | [**Claims denials on the rise, complicating revenue collection, survey finds**](https://www.healthcarefinancenews.com/news/claims-denials-rise-complicating-revenue-collection-survey-finds) | [[Healthcare Finance]] | | 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]] | | 9/25/2024 | [**Providers say claims denials are increasing: survey**](https://www.healthcaredive.com/news/provider-claims-denials-increase-2024-experian-health-study/727999/) | [[Healthcare Dive]] | | 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 | | 6/3/2024 | [**Compliantly supercharge your hospitals bottom line**](https://www.healthcaredive.com/spons/compliantly-supercharge-your-hospitals-bottom-line/717430/) | [[Healthcare Dive]] | | 3/21/2024 | [**Providers 'wasted' $10.6B in 2022 overturning claims denials, survey finds**](https://www.fiercehealthcare.com/providers/providers-wasted-106b-2022-overturning-claims-denials-survey-finds) | [[FierceHealthcare]] | | 12/13/2023 | [**Payers' increasing claims denials, delays 'wreaking havoc' on provider revenue cycles**](https://www.fiercehealthcare.com/finance/payers-increasing-claims-denials-delays-wreaking-havoc-provider-revenue-cycles) | [[FierceHealthcare]] | ## Topic Overview (Some LLM-derived content — please confirm with above primary sources) ### Key Players - **Health Care Service Corp.**: Health insurer with a 29% denial rate for in-network claims. - **Experian**: Conducts analyses on healthcare claims processing inefficiencies, including denial rates. - **UnitedHealthcare**: Another leading health insurer, reporting a 33% denial rate for in-network claims. - **Cofactor AI**: A startup that launched the Cofactor Denial Suite to streamline the appeals process for denied claims. - **Molina Healthcare**: Health insurer with a 26% denial rate for in-network claims. - **Vim**: A company supporting over 20,000 healthcare providers to address claim denials and prior authorization challenges. - **Sunknowledge Inc.**: A medical billing provider specializing in prior authorization and claims management, known for minimizing claim denials. - **Blue Cross and Blue Shield of Alabama**: A major health insurer with a reported 35% denial rate for in-network claims in 2023. - **NYC Health + Hospitals**: A healthcare system that successfully reduced claims denials by 50% over two years, saving $50 million in one fiscal year. - **Boost Healthcare**: Acquired by Aspirion to enhance capabilities in payment variance and denials management. - **Thoughtful AI**: An AI-powered revenue cycle automation company that has launched AI agents to automate claims processing and reduce denial rates. - **Iodine Software**: Offers advanced technology for clinical documentation improvement and appeals management to reduce claims denials. - **CommonSpirit Health**: Launched the AI assistant Insightli to improve documentation and mitigate risks in claims management. - **IKS Health**: A company that offers solutions to alleviate administrative burdens in healthcare, focusing on claims management and coding. - **Aspirion**: A company focused on revenue cycle management and claims denials, recently appointed Nick Giannasi as CEO to enhance its leadership. - **XpertDox**: A company that integrates AI medical coding software to enhance clinical documentation and reduce claim denials. - **Imagenet**: Provider of software and consulting solutions for health plans, enhancing claims and compliance capabilities. - **Conduent**: Recognized as a leader in healthcare payer operational transformation, automating enrollment processing and document digitization. - **Corti**: AI-driven medical coding solutions provider aimed at improving billing accuracy. ### Partnerships and Collaborations - **3Pillar Global**: Published an eBook outlining opportunities for organizations to improve revenue cycle and claims management efficiency. - **Aspirion and Boost Healthcare**: Aspirion's acquisition of Boost Healthcare aims to strengthen reimbursement recovery efforts and improve payment accuracy. - **XpertDox and Nao Medical**: Collaborated to integrate AI medical coding software into Nao Medical's revenue cycle management operations, resulting in a 22% reduction in claim denials. - **Valer and Clearwave**: Collaboration to automate prior authorizations and streamline patient intake processes. - **Tanner Health and Healthliant Ventures with Corti**: Strategic partnership to enhance healthcare operations through AI-driven medical coding solutions. - **HCA Healthcare and Commure**: Partnered to create an ambient AI platform to improve workflows in healthcare settings. - **Humata Health Funding Round**: Led by Blue Venture Fund and LRVHealth, with participation from Optum Ventures and Highmark Ventures. - **Xsolis and Beacon Health System**: This partnership has improved administrative processes, allowing the health system to support 140% more patients daily despite staffing challenges. - **Aspirion**: Appointed Nick Giannasi as CEO to lead advancements in healthcare technology revenue cycle management. ### Innovations, Trends, and Initiatives - **Cofactor Denial Suite**: An AI-powered platform designed to streamline the appeals process for denied claims by integrating with EHR systems. - **AI in Claims Processing**: Payers are increasingly using AI to enhance claims processing efficiency, leading to a rise in claims denials. - **AI in Claims Management**: Utilization of AI and machine learning to analyze denial reasons and automate claims processes, improving compliance and efficiency. - **Apprio IDP**: Launch of Intelligent Denial Prevention solution to reduce claim denials and improve patient care through advanced automation. - **AI and Automation**: Healthcare organizations are increasingly adopting AI and automation technologies to streamline claims processing and reduce denial rates. - **Appeals Management Workspace by Iodine Software**: Automates appeal letter generation and denial tracking to improve pre-claim denials management. - **Med Claims Compliance**: An innovative solution integrating AI technology with human oversight to enhance accuracy and streamline workflows in claims management. - **CMS New Rule**: Introduced to reduce denials in Medicare Advantage plans, aiming to alleviate prior authorization issues and improve access to healthcare. - **Revenue Cycle Automation**: Healthcare organizations are increasingly investing in AI and machine learning technologies to improve efficiency and reduce claims denials. - **Healthcare Information Exchange (HIE)**: Emerging as a crucial trend to enhance claim accuracy and reduce denials through real-time data sharing. - **Cloud-Based Solutions**: The shift towards cloud-based medical claims management systems is enhancing operational efficiency and reducing processing errors. - **Healthcare BPO Market Growth**: Projected growth in the healthcare BPO market, particularly in claims management services, driven by increasing hospitalization rates and insurance claims. - **Generative AI (GenAI)**: Emerging as a tool to assist in content creation and improve efficiency in clinical workflows, potentially reducing claims denials. - **Generative AI Applications**: The rise of generative AI is being leveraged to enhance claims processing and reduce administrative burdens. - **Legislative Changes**: The Centers for Medicare and Medicaid Services has implemented new rules to streamline prior authorization processes, potentially alleviating administrative burdens. - **AI in RCM**: AI is expected to revolutionize revenue cycle management by automating processes such as patient eligibility insights, billing coding, and appeals management. - **Generative AI Technology**: Humata Health plans to invest in generative AI to improve prior authorization submissions. - **Generative AI**: Utilized to streamline RCM by managing unstructured data, enhancing patient care, and optimizing financial operations. ### Challenges and Concerns - **Claims Denials Increase**: Medical coding denials have increased by 125% compared to last year, with clinical denials rising by 51%. - **Claim Denials**: Nearly 20% of Americans with marketplace insurance experienced claim denials in 2021, often without clear reasons, leading to unexpected bills. - **Rising Denial Rates**: Denial rates for healthcare claims have increased significantly, complicating revenue collection and leading to higher administrative overhead. - **High Denial Rates**: Providers are facing a 15% denial rate on approximately 3 billion medical claims processed annually, with hospitals losing an average of $5 million annually due to claims denials. - **High Claim Denial Rates**: Significant increase in claim denials, particularly in Medicare Advantage, leading to financial strain on healthcare providers. - **Rising Claims Denials**: Claims denials have surged, with reports indicating a 56% increase in 2023, costing the healthcare industry approximately $20 billion annually. - **Administrative 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. - **Criticism of Automation**: Patients and providers have raised concerns about the use of automation by insurers, which has been linked to rising claims denials. - **AI Misuse in Claims Processing**: Concerns over the use of AI in claims processing leading to increased denial rates and complications in patient care. - **Administrative Burdens**: Challenges in revenue cycle management due to staffing shortages and increased claims denial rates complicating financial sustainability. - **Impact of AI on Denials**: Poor applications of machine learning algorithms can lead to automatic denials without considering individual patient circumstances. - **Strained Payer-Provider Relationships**: Relationships between health systems and health plans have deteriorated, with many CFOs blaming health plans for increasing denials. - **Staffing Shortages**: 63% of healthcare providers face staffing shortages in revenue cycle management, leading to operational challenges and increased claims denials. - **Cybersecurity Threats**: Increasing cyber threats are complicating claims processing and raising concerns about data security in healthcare technology systems. - **Complexity of Payer Requirements**: Projected to increase, leading to higher denial rates and administrative burdens for providers. - **Administrative Costs**: Hospitals incur over 40% of patient care expenses from administrative costs related to prior authorization appeals, spending around $40 billion annually on billing and collections. - **Prior Authorization Issues**: 77% of healthcare professionals report that prior authorization processes delay patient care. ## Related Topics [[Claim Denials]]; [[Claims Reviews]]; [[Claims Management]]; [[Claims Processing]]