MDaudit joins the American Health Information Management Association (AHIMA) in a dynamic film series that shines a light on the vital work of health information (HI) professionals at the intersection of care, technology, and policy.
Health Information: Making Every Patient’s Story Matter showcases how HI professionals safeguard sensitive data, improve patient outcomes, and shape smarter and more connected healthcare systems through a series of short films, expert interviews, and real-world case studies.
Revenue Integrity and Care Quality
Produced in partnership with strategic content creator Content With Purpose (CWP) and available to stream online, the series features two films from MDaudit. The first is a short documentary that examines how healthcare professionals at Reno, Nev.-based Renown Health, Nevada’s largest not-for-profit integrated healthcare network, utilize MDaudit’s billing compliance and revenue integrity platform to prevent fraud, waste, and abuse, ensuring appropriate reimbursement and improving care quality.
Ritesh Ramesh
The second is an interview with MDaudit CEO Ritesh Ramesh, who shares insights into why some hospitals and health networks with strong profit margins can reinvest capital back into new and existing facilities to expand access and offer exceptional patient care despite surging denial rates.
These provider organizations tend to invest in advanced revenue cycle management (RCM) technologies, including AI and automation, to accelerate and improve the processing of health information, achieve revenue integrity, and optimize clinical and administrative operations. This, in turn, provides the financial sustainability necessary to expand provider organizations’ services and service footprint, including into traditionally underserved areas.
“The ability to avoid denials and optimize operations and reimbursements by implementing a pre-emptive continuous risk monitoring strategy within RCM is a significant advantage for high-performing healthcare organizations,” says Ramesh. “MDaudit plays an essential role in achieving proactive revenue integrity by helping healthcare organizations balance accurate revenue capture with risk mitigation, enabling confident reinvestment in the future of patient care.”
Revolutionizing Health Data
Filmed across North America, Health Information: Making Every Patient’s Story Matter highlights the innovation, expertise, and collaboration that drive excellence in the profession. It explores themes such as:
Data for Better Health – how patient data powers improved health outcomes and a deeper understanding of social determinants of health.
Emerging Technologies – the role of AI and digital tools in enabling accurate, secure, and accessible records.
Collaboration & Thought Leadership – how partnerships across governments, academia, and industry strengthen health systems.
Skills, Integrity & Certification – the value of credentials and professional standards in advancing healthcare transformation.
Together, these stories bring the HI profession to center stage, demonstrating how health information is revolutionizing the way data is created, exchanged, and utilized across healthcare. Explore the series here.
MDaudit, an award-winning cloud-based continuous risk monitoring platform for RCM that enables the nation’s premier healthcare organizations to minimize billing risks and maximize revenues, has finalized its acquisition of Streamline Health Solutions, Inc., a leading provider of solutions that enable healthcare providers to improve financial performance. The addition of Streamline’s pre-bill integrity solutions to its robust billing compliance and revenue integrity platform positions MDaudit to bridge crucial RCM gaps, thereby mitigating billing compliance risks and strengthening and streamlining the revenue cycle.
First announced in May, the acquisition brings together two healthcare RCM powerhouses supporting healthcare organizations with a combined net patient revenue of more than $300 billion. The companies’ shared belief in centering customer satisfaction while leveraging the latest technologies converges into a powerful platform capable of meeting head-on the revenue cycle realities confronting organizations in today’s complex healthcare environment.
Ritesh Ramesh
“Navigating the unrelenting financial and operational pressures of the current revenue cycle landscape requires a strategic approach to revenue cycle management, one in which real-time data, AI, analytics, and automation provide an uninterrupted view across the revenue cycle continuum,” says Ritesh Ramesh, CEO of MDaudit. “This acquisition allows us to provide healthcare organizations with the data- and AI-driven solutions they need to implement an effective, resilient, and adaptive RCM strategy.”
The award-winning MDaudit platform streamlines healthcare revenue integrity using augmented intelligence. It rapidly analyzes billions of rows of data, monitors coding, billing, and payment processes, and uses AI-powered tools to democratize insights and automate workflows. Benchmarking helps identify charge capture and denial issues, while retrospective audits drive staff education to prevent errors.
Streamline Health’s RCM solutions empower healthcare providers to manage and optimize their revenue streams more efficiently. Its suite of comprehensive solutions focuses on pre-bill charge and coding integrity, ensuring that all charges and coding are accurate before billing and payment. By preventing lost revenue and minimizing denials, Streamline Health enables providers to secure the reimbursement they deserve.
Cain Brothers, a division of KeyBanc Capital Markets, acted as exclusive financial advisor to Streamline, which is now a private company and wholly owned subsidiary of MDaudit. Troutman Pepper Locke LLP served as Streamline Health’s legal counsel. Goodwin Proctor, LLP served as legal counsel to MDaudit.
Healthcare organizations are engulfed in an intensifying storm of audits and denials exacerbated by heightened regulatory and payer scrutiny. Individually, any of these trends can endanger a hospital’s or health system’s financial stability. Combined, they represent a crisis calling for immediate action.
Healthcare finance leaders who wish to successfully guide their organizations across this increasingly complex and challenging landscape must transform their revenue cycle management (RCM) strategies. Central to this transformation is proactive risk monitoring and the implementation of AI-driven compliance strategies.
Mounting Pressure
According to the 2024 MDaudit Annual Benchmark Report, audit volumes more than doubled over 2023 rates while total at-risk dollars increased fivefold to $11.2 million, straining provider organization cash flows. That analysis, encompassing more than $8 billion in audited professional and hospital claims and over $150 billion in denials collected from more than 650,000 providers and more than 2,200 facilities, also found that payer scrutiny is at an all-time high.
Medicare Advantage (MA) plans are a favorite target, with HCC and RADV audits—which help ensure health plans and providers are paid appropriately based on the actual health of their members—rising by 72% and total MA denials by 51%. Denials related to how providers code their claims increased by 126%, representing one of the most significant increases in the last three years. Denials surged across care settings; hospital inpatient-related denials were up nearly 220% to $10,000 per claim, hospital outpatient by 32.5% to $825, and professional by 24% to $140.
While the data clearly demonstrates that coding integrity is one of the biggest revenue optimization opportunities in healthcare, documentation around the medical necessity of care provided also urgently needs improvement. The MDaudit analysis revealed a 140% increase in total denial amounts for inpatients and a 75% increase in outpatient amounts related to the “Medical Necessity and Information Needed” category. Overall, more claims dollars were denied in 2024 by Medicare and commercial payers due to a lack of information submitted for the service and medical necessity, driving an increase in final denial dollars across professional (34%), hospital outpatient (84%), and hospital inpatient (148%).
Behind these increases was a doubling of external audit volumes, which included a sizable jump in pre-payment audits. These audits can interfere with cash flow and increase overall denial rates.
Fraud prevention is adding to the complexity of today’s healthcare financial landscape. According to the US Department of Health and Human Services (HHS) Office of the Inspector General (OIG) Health Care Fraud and Abuse Control Program Report for Fiscal Year (FY) 2023, released in December 2024, federal recovery efforts targeted $4.7 billion in projected overpayments within MA alone, a figure expected to rise as the Centers for Medicare and Medicaid Services (CMS) ramps up fraud prevention.
Fiscal year 2023 saw civil healthcare fraud settlements and judgments under the False Claims Act exceed $1.8 billion, bringing the total amount returned to the federal government or paid to private individuals to more than $3.4 billion. This figure includes $974 million returned to the Medicare Trust Funds and $257.2 million in federal Medicaid funds transferred separately to the CMS.
Transforming RCM Strategies
The shift toward more aggressive pre-payment audits, a greater focus on fraud, and tactics to prolong reimbursement delays underscore the need for a revenue strategy that prioritizes revenue optimization and risk mitigation. Built upon a foundation of AI, automation, and other technology tools that enable continuous monitoring of real-time financial risk based on payer trends and denial management, this transformative revenue cycle strategy delivers a significant return on investment (ROI). It also introduces automated workflows that drive operating margins.
Streamlining and improving audit response is essential for enhancing providers’ revenue capture, particularly as payer organizations increasingly rely on pre-payment audits to delay reimbursements and increase denial rates. Investing in AI, machine learning (ML), and automation tools that deliver intelligent functionality to automate and accelerate the management of external payer audits ensures the timely processing of additional documentation requests (ADRs), thereby improving audit defense outcomes and revenue retention.
Generative AI and natural language processing (NLP) solutions further optimize audit outcomes by unlocking insights and patterns from historical data while also increasing accessibility and democratizing information across the revenue cycle. For example, generative AI tools that take natural language questions and instantly compute complex formulas to return clear, concise, and actionable responses boost human productivity and deliver speed-to-value. They eliminate information silos between revenue integrity and executive teams, transforming how they interact with data to make more innovative and strategic decisions.
Transforming the Revenue Cycle
Strong internal compliance programs and a cross-functional operating model that connect the dots between billing, coding, CDI, and revenue integrity will advance a unified revenue retention and growth agenda. Leveraging data and insights as a storytelling mechanism enhances program value by removing bias and injecting objectivity into discussions and decision-making while establishing success metrics introduces accountability for tangible outcomes.
With the core strategy in place, finance executives can look to other targets for RCM transformation to enable healthy operating margins, such as high-value outpatient services like elective surgeries and some inpatient services. Along with scrutinizing complex services, other opportunities to improve revenue retention include implementing clinical documentation improvement (CDI) programs that drive outcomes tied to RCM and denial management metrics.
CDI, billing, coding, and RCM programs can also be tightly coupled to implement a closed feedback loop from the backend to the mid-cycle, driving efficiencies. Finally, automate coding operations and increase the utilization of AI-powered systems that amplify errors at scale while keeping humans in the loop.
Deploying technologies that bridge mid-cycle and back-end functions will drive more substantial margins and cash flow while mitigating risks tied to payer-driven policies and denials. An aggressive AI-enabled, data-driven, and people-led approach to the revenue cycle allows forward-looking finance leaders to position their organizations for financial survival in today’s high-risk landscape.
MDaudit, a portfolio company of Bregal Sagemount & Primus Capital and an award-winning cloud-based continuous risk monitoring platform that enables the nation’s premier healthcare organizations to minimize billing risks and maximize revenues, and Streamline Health Solutions, Inc., a leading provider of solutions that enable healthcare providers to improve financial performance, announced today that they have entered into a definitive merger agreement pursuant to which MDaudit will acquire Streamline.
This combination brings together two organizations that share a common vision: enabling healthcare organizations to expand patient care and access by improving financial stability. By joining Streamline’s pre-bill integrity solutions with MDaudit’s robust billing compliance and revenue integrity platform, the parties believe that the combined organization will be uniquely positioned to unify disparate data silos, broaden executive insights, and drive coordinated actions across the revenue cycle continuum to accelerate revenue outcomes and mitigate risk.
Ritesh Ramesh
“At a time when health systems are facing mounting financial and operational pressures, we believe the future belongs to those who can connect the dots across the revenue cycle continuum with data- and AI-driven solutions,” said Ritesh Ramesh, CEO of MDaudit. “Streamline’s RevID and eValuator solutions complement MDaudit’s current strengths in billing compliance and revenue integrity capabilities by enabling pre-bill visibility in real-time to unlock revenue opportunities. These solutions reflect our shared belief that human-driven revenue cycles deserve proactive, systemwide intelligence with closed feedback loops that are actionable”.
“MDaudit and Streamline have always believed that the most sophisticated technology won’t drive successful outcomes without an unwavering focus on customer satisfaction,” said Ben Stilwill, CEO of Streamline Health. “Our teams have built trust by being true partners to our customers. Together, we’re building a broader platform that reflects the reality of today’s revenue cycle: distributed teams, disconnected data, and immense responsibility. Together, we’re delivering foresight and action; not just reports or alerts.”
Transaction Summary
At the effective time of the merger, a wholly-owned subsidiary of MDaudit will merge with and into Streamline, with Streamline surviving the merger as a wholly-owned subsidiary of MDaudit. The closing of the transaction is subject to certain customary closing conditions, including approval of the merger agreement by the Streamline stockholders. The transaction is not subject to a financing condition, and MDaudit intends to finance the transaction using a combination of cash on hand and available funds from existing credit facilities.
The merger is expected to close during the third quarter of 2025. Following the closing of the merger, Streamline’s common stock will no longer be listed on the Nasdaq Stock Market, and Streamline will become a private company.
MDaudit, an award-winning cloud-based continuous risk monitoring platform for RCM that enables the nation’s premier healthcare organizations to minimize billing risks and maximize revenues, today announced the latest AI-powered enhancement to its award-winning revenue integrity platform.
AI Assist leverages artificial intelligence (AI), machine learning (ML), and natural language processing (NLP) to instantly transform an overwhelming volume of billing, audit, and payment data into clear, intelligent, and actionable insights.
Intuitive and easy to use, revenue integrity professionals simply type in their questions in natural language into AI Assist, which automatically computes complex formulas and instantly returns clear, concise, and actionable responses, regardless of the query’s complexity. AI Assist is also intuitive, ensuring that follow-up questions are addressed as precisely as the original query and as quickly as they would be if they were posed during a discussion with RCM peers.
“Effective revenue cycle management hinges on strategic decision-making informed by actionable insights that drive financial outcomes. More data behind those insights should translate into better decisions, not greater risk. Yet absent the proper tools to manage it, the sheer volume and complexity of healthcare data can overwhelm even seasoned RCM professionals. AI Assist is transformative in this situation,” says Lee-Ann Ruf, Senior Vice President, Product Management, MDaudit.
Ritesh Ramesh
“AI Assist boosts human productivity and speed-to-value by transforming how revenue integrity teams interact with data to make smarter and more strategic decisions. We are leveling the playing field by preventing these teams from getting bogged down by the need for highly technical or advanced data analytics skills,” says Ritesh Ramesh, CEO, MDaudit. “Whether identifying top denial drivers, tracking audit outcomes, or uncovering revenue opportunities, AI Assist maximizes operational efficiency to understand revenue risks and opportunities. It is simple to use and does not require AI expertise or experience.”
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.
MDaudit, an award-winning cloud-based continuous risk monitoring platform for RCM that enables the nation’s premier healthcare organizations to minimize billing risks and maximize revenues, announced today that its MDaudit billing compliance and revenue integrity platform is a finalist in the 2024 Fierce Healthcare Innovation Awards.
MDaudit is a finalist in the Data Analytics/Business Intelligence category, which recognizes innovative data analytics tools that bring actionable information directly to users by either enabling the wide dissemination of clinical, financial or operational data, or helping them make sense of it. Currently, more than 1 million cases and $8 billion in charges are audited annually on the MDaudit platform and more than $150 billion in denials are analyzed for potential reimbursement. Additionally, more than 5 billion claims are used for benchmarking via MDaudit.
Ritesh Ramesh
“The innovation strategy at MDaudit starts with our customers; they are at the center of everything we do,” said Ritesh Ramesh, CEO, MDaudit. “This recognition from Fierce Healthcare is a huge acknowledgment of our effort to deliver tangible business outcomes to our customers in the U.S. healthcare system. A huge shout out to our team and partners who work with us diligently every day to innovate and make a difference.”
From Questex’s Fierce Healthcare, Fierce Biotech and Fierce Pharma, the Fierce Healthcare Innovation Awards identify and showcase outstanding innovation that is driving improvements and transforming the industry. Two expert panels of judges determined which innovative solutions demonstrated the greatest potential to save money, engage patients, or revolutionize the industry based on effectiveness, technical innovation, competitive advantage, financial impact, and true innovation. Winners will be announced in the Innovation Report on December 2, 2024.
In a LinkedIn post announcing the 2024 finalists, Fierce Life Sciences Events wrote, “These forward-thinking organizations have demonstrated excellence in healthcare technology, patient care, operational advancements, and more, setting new standards across the industry. Their innovations are transforming healthcare delivery and improving patient outcomes.”
Revenue integrity has become harder to maintain as audits grow in volume and complexity. Payers are increasing scrutiny and regulatory agencies are reinforcing fraud mitigation. Navigating this evolving terrain requires a reimagined, automated approach to billing compliance, coding, and HIM, optimizing accuracy and efficiency to protect revenue.
We sat down with Dana Finnegan, Director of Market Strategy with MDaudit, to discuss what’s behind the scenes of reimagining revenue integrity and the role automation can play in achieving success.
EHR: What is driving the need for hospitals and other healthcare organizations to reimagine their approach to revenue integrity?
DF: We’ve identified four trends that are influencing the need for healthcare organizations to take a fresh approach to revenue integrity, maximize reimbursement and compliance outcomes, and optimize operational efficiency—all of which are critical to sustaining long-term results.
First, the average denied dollars per claim continues to rise. MDaudit data shows an overall increase in denied dollars per claim of more than 19% between 2023 and 2024 and a whopping 62% increase in Medicare Part A and B denials during that same period. At the same time, initial response times to claim submissions are also trending up and, once again, Medicare is the driver. Professional response time has increased by nine days, from 15 in 2023 to 24 this year, while hospital outpatient response days increased from 15 to 19 and hospital inpatient increased from 18 to 22 days.
A third trend we’re seeing is in denial rates, which were 21% for hospital outpatient and 27% for hospital inpatient segments. Finally, dollars at risk from external payer audits have doubled, with hospital billing driving most of the external audits in terms of risky dollars and commercial payers and RAC driving most external audits in terms of volume.
The good news is that we are also seeing an increase in technology investments among healthcare provider organizations, especially AI and automation, to push back against these trends and gain a competitive advantage in terms of revenue integrity.
EHR: How can automation provide a competitive edge in terms of revenue integrity?
DF: Manual healthcare billing audits are resource-intensive and prone to human error. The intricate nature of billing compliance, revenue integrity, and coding demands meticulous attention to detail, which makes it susceptible to oversights and discrepancies.
Consider that the 40 largest U.S. health systems average just under 55 hospitals per system, and bill to a wide mix of government and commercial insurance plans. Commercial, private and self-pay represent the largest payer group for U.S. hospitals with net patient revenue of nearly $689 billion, or just over 69% of the average payer mix. Clearly, billing compliance is a complex, high-stakes game even without the added scrutiny from payers and regulators.
Automating manual processes is a pivotal advancement during what is a very challenging time for the industry. Automated audit processes help billing compliance teams locate the proverbial “needle in the haystack” by identifying the highest billing risk patterns and mitigating risk while maximizing revenue—and it does so faster and more accurately than any human could manage. This lets providers stay on top of the rising flood of demand letters that regularly flow through their doors and leverage the power of data analytics to drive meaningful audit outcomes.
MDaudit
