Amid a 125% rise in coding-related denials and a 140% increase in inpatient medical necessity denials, 2025 will see healthcare providers deploying real-time financial risk monitoring as a cornerstone of stability.
Adding to the urgency around overhauling revenue cycle management (RCM) strategies to prioritize revenue optimization and risk mitigation is a fivefold increase in total “at risk” dollars to $11.2 million and a doubling of external audit volume in 2024 over 2023—including a sizable increase in pre-payment audits and their propensity to exacerbate cash flow issues and expose providers to potentially higher denial rates.
These headwinds, coupled with slower reimbursement timeframes, tempered any gains from improved revenues and operating margins in 2024 and threatened healthcare providers’ financial stability—a backdrop of challenges that are among the key findings of the recently released 2024 MDaudit Annual Benchmark Report.
The annual report’s findings elevate the transformation of RCM into a strategic imperative for health systems in 2025. They highlight the pressing need to continuously monitor financial risk to proactively mitigate issues before they impact operations.
Impending Financial Risks
The Benchmark Report is a comprehensive examination of real-world data representing the first three quarters of 2024 collected from a network of more than 650,000 providers and over 2,200 facilities that provide data to MDaudit for auditing, charge analysis, and denial assessment. It encompasses insights from more than $8 billion in audited professional and hospital claims and more than $150 billion in denials by commercial and government payers. Over 5 billion claims and remits were used for benchmarking.
At the end of the year, it is both natural and vital to spend time reflecting on the highs and lows of the past 365 days (or, in the case of 2024, 366 days). Much like its predecessors, 2024 was full of rapid change, incredible innovation, and persistent challenges. As we brace for another transformational year ahead, it’s clear that technological and political tailwinds will drive big shifts across the industry.
From AI-driven innovations to sweeping government reforms, opportunities and risks abound – which makes it even more critical for healthcare executives and leaders to have practical insights for navigating the uncertain times ahead. This Q&A dives into some of the biggest factors expected to impact healthcare in 2025 and offers advice to ensure that businesses and policies can drive meaningful progress for the healthcare industry and the people it serves.
Knowing how to control bleeding quickly and effectively—and having the right equipment on hand—saves lives in the case of a traumatic accident. There are several effective ways to control bleeding in an emergency.
How you control bleeding largely depends on the severity and source of the bleeding. Informing yourself about how to treat a penetrating chest wound, head injury, or an injured limb prepares you for different critical situations.
Important: Assess the Situation Before Giving Emergency Care
Bystander emergency care is critical to the outcome of a bleeding emergency. As the first responder, the actions you take between calling 9-1-1 and the EMTs arriving will potentially save a life. Take the following steps to assess the gravity of the situation and decide what care to give:
Examine the wound(s) and the injured person: Quickly assess the nature and severity of the injury, including the size and depth of the wound. Look for signs of shock like pale skin, a rapid heartbeat, or shallow breathing. Check for any other injuries or conditions that may be contributing to the bleeding. Remember that severe wounds may not be immediately obvious.
Identify the severity of the bleeding: Determine if the bleeding is severe, moderate, or minor based on the amount of blood loss and the injured person’s condition. Consider the location and type of injury and which of the following strategies you should use to control the bleeding.
Apply Direct Pressure
Using gauze or a cloth to apply direct pressure to the wound is sometimes enough to control moderate bleeding. The best bleeding control kits contain different types of gauze and bandages to pack and maintain pressure on wounds.
How to Apply Direct Pressure to a Wound
Use sterile gauze (or a clean cloth) to apply direct pressure to the wound site.
Apply steady, firm pressure for at least 5-10 minutes or until the bleeding stops (if this occurs sooner).
Raise the wound above heart level to reduce blood flow if possible.
If the bleeding doesn’t slow to a trickle after a minute or so, proceed to wound packing and/or tourniquet application (depending on the location of the wound).
Wound Packing
Wound packing is a technique used to control severe bleeding, particularly from deep wounds. It involves filling a wound cavity with sterile gauze or other absorbent material to apply direct pressure to the bleeding source and promote clotting.
Wound packing is particularly effective for controlling bleeding from deep wounds like gunshot or stab wounds or other penetrating injuries that prove difficult to control with only direct pressure.
How to Pack a Wound
To pack a wound, stuff a deep wound with regular or hemostatic gauze or a clean cloth if gauze isn’t available. Apply pressure directly to the top of the wound with both hands. Push down as hard as you can until an EMT relieves you.
Wound packing can be highly effective. However, as Brian Graddon, ex-firefighter paramedic, SWAT medic, and CEO of True Rescue explains, wound packing isn’t always the best course of action for treating certain wounds:
By Meredith Kirchner, COO and chief client success officer, Curae.
Emergency rooms and specialty care facilities, like infusion and burn centers, serve millions of patients annually in urgent, often life-saving situations.
For many patients, however, these visits are accompanied by steep out-of-pocket expenses they are unprepared for, leaving them with overwhelming medical bills.
At the same time, healthcare systems bear the financial burden of these high-cost care episodes, as nearly 70% of emergency care services can go un- or under-compensated. This dual financial strain places immense pressure on healthcare leaders, who have no choice but to find ways to address both patient affordability and their system’s own financial sustainability.
The Emergency Medical Treatment and Labor Act (EMTLA) plays a significant role in this – enacted in 1986, EMTLA requires emergency departments to screen and stabilize patients regardless of their ability to pay or current insurance status. While this law does ensure access to critical care for all, it prevents physicians from discussing costs or payments until after stabilization. For many patients, this means they are largely unaware of their financial responsibility until the bill arrives, often weeks later.
This dynamic leaves both patients and healthcare systems vulnerable: patients face financial stress that impacts their well-being, while uncollected balances contribute to rising bad debt for health systems.
The impact of increased patient financial responsibility cannot be overstated. With health insurance plans shifting more costs onto patients through higher deductibles and coinsurance, many are left unable to pay their share of medical expenses.
In fact, individuals in the top 10% of healthcare spenders face average annual out-of-pocket costs of over $6,000, while those in the top 1% spend an average of nearly $25,000. Not only do these expenses result in financial stress, but they can also lead to delayed payments and avoidance of future care.
These unpaid balances, combined with the administrative cost of collections, put health systems in a difficult position. Revenue losses from high-cost care episodes limit the ability to reinvest in critical areas like staffing, equipment, and technology, further weakening the organization’s overall financial and operational stability.
Gaining Coverage – Eligible Patients for ACA Plans
Many patients diagnosed with significant diseases and conditions are underinsured or uninsured. A good first step for health systems is to check the patient’s eligibility for an Affordable Care Act (ACA) plan.
Health systems often have service providers and in-house patient advocates perform this work to help complete the enrollment. The coverage in a platinum plan will cover much of the cost of the care (e.g. in-patient stay, infusion therapy and drug cost, oncologist professional fees, etc..), however even if the patient is eligible for an ACA plan and enrolls, there are co-pays and deductibles as with any commercial insurance plan, which could be thousands of dollars for each infusion therapy or procedure.
With or without insurance coverage, patients need medical service financing for out-of-pocket costs over $1,000 and especially for large costs associated with more severe diagnosis and therapies and procedures.
Proactive Financing Programs
Patient financing programs offer a proactive solution to this growing issue. By providing flexible payment options at critical points of care, health systems can reduce the financial strain on patients, improve cash flow, and minimize bad debt. As high-cost care episodes continue to rise, adopting these programs is not just a strategy for maintaining access to care—it’s essential for ensuring the financial resilience of health systems.
In addition, the current economic and regulatory landscape is making patient financing programs more essential than ever. Rising interest rates make traditional payment plans less viable for both patients and health systems, while state laws are increasingly limiting how providers can pursue unpaid medical bills. In fact, many states now prohibit providers from selling patient debt or collecting from low-income individuals, leaving health systems to absorb the cost.
Patient financing programs can provide a compliant, patient-centric alternative that ensures financial stability while avoiding aggressive collection practices. These programs, often managed by third-party institutions, allow patients to cover their expenses over time, reducing immediate financial stress and improving payment adherence. Direct benefits of patient financing programs include:
Improved Access to Payment Options: Patients can pay in manageable installments, reducing financial strain.
Enhanced Financial Stability for Health Systems: Financing minimizes unpaid balances and strengthens cash flow.
Increased Patient Satisfaction and Trust: Providing financial solutions builds confidence and encourages future engagement.
The Role of Technology in Patient Financing
Technology is a critical component of patient financing programs, enabling healthcare systems to manage the process efficiently and with precision. Eligibility for financing can be determined through integration with the electronic health record software (EHR) to provide a seamless workflow for the staff member to provide a financing application quickly to the patient, and then to quickly be able to satisfy the balance with that newly created line of credit.
Once eligibility is determined, these systems provide patients with clear and transparent repayment options. Interactive digital portals or mobile applications allow patients to view, select, and agree to financing terms directly from their devices. Tools like these simplify communication, ensuring patients fully understand their financial responsibilities and repayment timelines as quickly as possible.
The application and enrollment process itself is streamlined through automation, reducing paperwork and manual input. For example, once a patient is approved for financing, the system can automatically generate and process the necessary agreements, set up payment schedules, and send reminders for upcoming payments. Automation not only reduces administrative workloads but also minimizes errors, validates entered information, and therefore improves successful enrollment with speed.
These technologies can also enhance compliance with regulatory standards, such as financial disclosures and data security. Built-in safeguards can ensure that patient financial information is handled according to federal and state regulations, protecting both the patient and the healthcare system.
Looking to the Future
The challenges posed by high-cost care episodes require health systems to rethink how they approach financial engagement. Patient financing programs represent more than just a way to address unpaid balances—they are a means of strengthening trust between patients and healthcare systems. By attempting to alleviate financial stress, these programs may encourage patients to seek necessary care earlier, possibly leading to better outcomes and fewer costly complications.
As we look ahead, patient financing programs are essential to navigating the intersection of patient affordability and organizational sustainability. Systems that embrace these solutions are not just managing today’s financial pressures—they are setting the stage for a more equitable and resilient healthcare system. By prioritizing programs that balance financial stability with compassionate care, health systems can lead the way in creating a future where patients feel supported and organizations remain strong enough to meet the growing demands of their communities.
Patient financing is no longer just a solution for high-cost episodes; it’s a cornerstone of modern healthcare strategy—one that aligns the needs of patients with the priorities of health systems in a way that is both sustainable and forward-thinking.
By Venkatgiri Vandali, president of healthcare and life sciences, Firstsource.
AI is a natural fit in multiple functions across the health plan value chain. In 2025, more plans will deploy generative AI in claims operations, the contact center, quality assurance, training and more.
These areas will become more efficient. In addition, health plans that use AI tools to solve perennial pain points, make employees more productive and deliver better member and provider experiences will start to pull away from competitors.
Why are generative AI and related tools such as machine learning able to deliver more value?
In the past, it took a long time for people to refine their requests to get the data they required. It often meant asking IT for help and could take days. Now AI makes it possible to essentially talk to machines and receive content in real time. This creates tremendous efficiency that will lead to cost reduction and ultimately more value for payers and members.
As an example, generative AI tools quickly extract relevant content from emails, claims, contracts, medical records and more. That minimizes the need for staff to look up information, expedites service processes and increases opportunities for automation. These efficiencies can net considerable time and cost savings while improving services.
What are AI copilots and AI agents and how do they help?
AI copilots work alongside humans, looking up information, flagging potential errors and suggesting next best actions. AI agents run in the background. Multiple autonomous AI agents can work together to exchange information and act based on business rules in “agentic workflows.”
An AI copilot could oversee an agentic workflow in which AI agents verify member data on a claim is accurate; check and correct edit codes; then evaluate whether the claim will adjudicate successfully. If the agentic workflow determines there’s an issue with the claim, the AI co-pilot will flag the potential issue for an expert human associate to mitigate.
What are some of the major efficiency gains payers can expect from AI?
Generative AI has the ability to manage massive amounts of data and yet also find a needle in that data haystack. This capability did not exist before generative AI and is invaluable to any operation that requires analytics and where resolution speed is critical. For example, things can go wrong in five million claims for a variety of reasons. Before AI, a payer would have to retroactively identify and correct the issue. Today, generative AI can constantly be talking to the system, monitoring claims, following up, ensuring claims are routed and processed correctly. Generative AI can also recognize when something is wrong. Then it routes the claim back to human stakeholders and alerts them to the problem.
By Joe Spinelli, chief strategy officer, Aranscia.
2024 left us with raw emotions, sentiments, and uncertainty around how the US healthcare system will support both the commercial and political promises of excellence and value in care for all.
Faced with ever-escalating costs, and rate-limited access to effective care for an increasingly greying population, we are left with no choice but to embrace novel approaches to identifying, facilitating, and incentivizing proactive care improvement and efficiencies. The only thing certain about 2025 is that it will not be business as usual.
Initiatives to further the personalization of health care extend beyond embracing best practices for high-risk and high-cost cohorts – they also empower the broader population of patients and clinicians with access to evidence-based insights to drive both proactive and preventive benefits. The field of personalized medication management and the utilization of drug-gene testing (also known as pharmacogenomics, or PGx) can truly support a trifecta of improving access, efficiency, and economics.
What problems can personalized medication management solve?
Adverse drug events are the fourth leading cause of preventable death in the US, and downstream issues related to ineffective medications or unwanted side effects create a significant cost and care burden on our healthcare system. In contrast to one-sized-fits-all prescribing, which has traditionally aligned care providers and pharmacy benefits with a “standard” regimen irrespective of its assessed compatibility with the patient, personalized medication management programs use a combination of tactical diagnostic testing and high-evidence clinical insights to assist providers in optimizing therapeutic decisions.
How are biomarker programs like PGx being embraced nationally?
Widespread state and federal initiatives have recognized the value and benefit of improving the accessibility of PGx testing. Over half of the US states now have legislation in force or introduced to enhance coverage for biomarker testing programs like PGx, and they have overwhelmingly received bipartisan support.
While the federal legislative priorities for 2025 and beyond remain uncertain, key thematic elements of personalized care, use of evidence-based science, and operational efficiency are highly compatible with the key tenets of PGx programs at scale.
When it comes to providing comprehensive preventive care, more than annual checkups are required. A patient-facing approach is needed to support the establishment of a health-forward routine comprised of proper nutrition and exercise, mental and emotional health, and chronic condition management.
Numerous studies back this preventive care model, which produces wide-ranging benefits, from improved health outcomes to lower care utilization to lower healthcare costs.
Unfortunately, despite its known benefits, the US healthcare system has been slow in its uptake of preventive care for many patients; just 8% of Americans currently undergo routine preventive screenings and care. As a result, the US loses about $55 billion annually due to missed prevention opportunities. That’s about $0.30 for every dollar spent on healthcare services.
Reversing these trends is the driving force behind the growing interest in lifestyle or preventive medicine and the adoption of technology tools to support physicians and patients in this approach.
Emergence of Lifestyle Medicine
Lifestyle medicine uses evidence-based, whole-person, prescriptive behavioral, and therapeutic lifestyle interventions to prevent, treat, and manage chronic diseases such as cardiovascular diseases, type 2 diabetes, and obesity. By integrating the six pillars of lifestyle medicine—nutrition, physical activity, stress management, restorative sleep, social connection, and avoidance of risky substances—into patient care, lifestyle medicine helps patients improve their health and well-being.
A lifestyle or preventive approach to medicine can address up to 80% of chronic diseases and potentially reverse the decades-long rise in the prevalence of chronic conditions and associated costs. It can also improve both patient and provider satisfaction. This aligns with the Quintuple Aim of better health outcomes, lower cost, improved patient satisfaction, improved provider well-being, and advancement of health equity.
By Grace Nam, Strategic Solutions Manager, Laserfiche.
As the healthcare industry continues to grapple with the dual challenges of rising costs and evolving patient expectations, the urgency to modernize and automate has never been greater.
A recent Deloitte report reveals that 75% of life sciences executives have a positive to cautiously positive outlook for 2025, signaling optimism despite ongoing challenges.
This optimism is rooted in the sector’s ability to innovate, leveraging technology to drive operational efficiency and improve patient outcomes.
With aging populations and increased demand for digital healthcare solutions, organizations must adapt quickly to remain competitive in a rapidly changing landscape. From integrating automated data processes to centralizing patient records, modernization is no longer a luxury—it is a necessity. These technological advancements not only streamline administrative tasks but also set the foundation for a more patient-centric approach to care. As we move into 2025, the industry stands at a critical crossroads, where the adoption of cutting-edge solutions will determine its trajectory for years to come.
Modernizing Legacy Systems
The modernization of legacy systems will be a cornerstone of healthcare innovation in 2025. Many institutions are shifting toward centralized and structured document management through integrated solutions. This approach streamlines operations, reduces manual processes, and lays the foundation for scalable automation. Tools that auto-extract and auto-populate healthcare data are increasingly becoming the norm, driving operational efficiency and improving data accessibility for healthcare staff.
These advancements not only reduce administrative burdens but also enhance the patient experience. Automation plays a critical role in managing patient information and streamlining tasks, such as appointment scheduling, billing, and record management. Younger generations, in particular, are pushing for rapid, digital-first engagement, favoring seamless interactions over traditional methods. By investing in these technologies, healthcare providers can better meet these expectations, creating a more responsive and patient-centric system.
Knowing how to control bleeding quickly and effectively—and having the right equipment on hand—saves lives in the case of a traumatic accident. There are several effective ways to control bleeding in an emergency.
By Grace Nam, Strategic Solutions Manager,