Healthcare organizations can no longer afford to treat revenue integrity as a problem to be addressed after a claim is denied. As reimbursement pressures intensify and both payers and providers turn to artificial intelligence to analyze claims, identify anomalies and automate processes, health systems need a more proactive approach to protecting revenue while maintaining compliance.
Ritesh Ramesh, CEO of MDaudit, believes that shift requires more than deploying new technology. It means bringing data, people and processes together across coding, compliance, auditing and revenue cycle operations, while using AI where it can deliver measurable business value.
Ramesh recently spoke with Electronic Health Reporter about the changing revenue integrity landscape, the growing “AI versus AI” dynamic between payers and providers, the importance of keeping human judgment in the loop, and what healthcare organizations should consider as they invest in AI-driven revenue cycle strategies.
Healthcare organizations have traditionally focused on managing denials after they occur. Why do you believe that approach is no longer sufficient in today’s reimbursement environment?
The reactive approach to denials management is no longer feasible, as the denial volumes, dollars per denial, and adjudication days per claim have grown incrementally over the years. According to our 2025 Benchmark Report, the average amount per coding-related denial increased 28% from 2023 to 2025. Health systems are under tremendous financial pressure due to a tighter reimbursement and policy environment, and a reactive approach will further stretch their already thin cash flow. Leveraging data, insights, and technology will help them proactively identify denial trends, fix issues before claims are paid, and stay two steps ahead of payers.
You’ve spoken about “Revenue Integrity Redefined.” What does that concept mean in practical terms for health systems, and why is now the right time to rethink traditional revenue integrity strategies?
Revenue integrity is the sustained alignment of three outcomes: reimbursement that reflects the care delivered, compliance that withstands payer and regulatory scrutiny, and operations efficient enough to hold both at enterprise scale. When you pursue any one of the three in isolation, the other two erode. With the advent of AI, now is the right time to transform the people and process dimensions so revenue integrity strategies can be successful. Technology can enable outcomes, but it cannot replace the people and process dimensions in the health system revenue cycle. Investments in technology should be balanced with process reengineering and upskilling people in new technologies.
Many healthcare organizations still treat revenue integrity as a department rather than an enterprise-wide strategy. What mindset shift needs to happen at the executive level?
Enterprises that drive successful revenue integrity strategies leverage a scalable technology platform; stand up a cross-functional program across billing compliance, coding, and revenue cycle; share insights and knowledge; track KPIs that matter; and make measurable progress toward the three outcomes: optimal reimbursement, compliance, and operational efficiency. They don’t see a successful revenue integrity program as a short-term, transactional approach to get claims paid today; they focus on fixing difficult, long-term processes and data issues across the revenue cycle continuum, so these issues don’t recur.
Some cross-functional programs need a strategic charter, actionable KPIs, change management, and business sponsorship to break departmental silos and office politics. This is where executives can drive their revenue integrity vision for the enterprise and align their respective teams to play together as one team.
AI and the Future of Revenue Cycle
Payers are increasingly using artificial intelligence to review claims and identify anomalies. How should providers respond to this changing landscape?
Providers must centralize their claim, payment, and clinical data and glean insights to identify issues and trends before payers report them. A continuous monitoring program and investments in technology platforms that can identify billing, coding, and payment anomalies in real time are the needs of the hour. This will allow them to respond to payers’ use of AI and their investments in this area in a timely and effective manner
AI has become one of the biggest topics in healthcare technology. Where do you see it delivering the greatest value in revenue cycle management today, and where do you think expectations may be getting ahead of reality?
AI has the highest potential to eliminate many manual administrative tasks and automate many parts of the healthcare revenue cycle. Many industry analysts see a world where the cost-to-collect metric will go down for health systems over the next decade because AI and agents help them keep more profits to invest in patient care. Lots of folks hear the word “autonomous” and think AI is a magic wand. I urge them to view AI like any other technology: it needs process and people to succeed. Many AI projects fail because of poor process design and a lack of talent upskilling.
Workforce shortages continue to challenge HIM, coding, and revenue cycle teams. How can AI and intelligent automation help organizations do more with limited resources while maintaining compliance and coding accuracy?
AI can really help with repetitive and mechanical tasks. It can scale exponentially across millions of rows of data and a voluminous number of tasks. When it goes properly, it’s beautiful to watch. When it fails, errors can be amplified, resulting in heavy financial losses. AI governance is critical. With a shortage of expertise in coding and revenue cycle, automation coupled with process and workflow redesign is critical to free those experts to focus on the parts of the process that require human judgment, including validating AI results and handling high-stakes areas.
Payers are increasingly using AI to identify potential claim issues, while providers are also turning to AI to improve audit readiness and revenue integrity. How is this accelerating “AI versus AI” dynamic changing the role of the human auditor, and why is keeping human judgment in the loop becoming more important rather than less?
AI can never be a substitute for human judgment and clinical expertise. It can be trained on large volumes of data sets to find patterns and help identify issues quickly so health systems can act. Providers must invest in AI to level the playing field and accelerate responses to payer queries and denials. Someone recently told me that AI will help them reduce denials. I replied that AI would help them defend the services provided, but it doesn’t expand the insurer’s risk premium pool, which can only pay a finite number of claims. It’s much more important for providers to defend the services they provided in days than for systems to integrate and analyze data for months. They will be left behind.
There has been a lot of discussion about AI adoption in healthcare, but less about proving measurable value. What does “Meaningful AI” mean in practice, and what should healthcare organizations look for to ensure AI investments deliver ROI, reduce operational friction, and strengthen decision-making rather than simply add another technology layer?
Meaningful AI is a framework with five components: data, models, workflow, security controls, and humans in the loop. The whole goal of this framework is to be pragmatic in leveraging AI in use cases with tangible business value. This can be reducing process friction, capturing revenue, or reducing risk. When designing an AI system, people should say, “This use case is not fit for AI because it does not produce any tangible benefits.” Meaningful AI brings that scrutiny and clarity to where AI is applied and what it produces for end users.
Leadership and Industry Outlook
Many healthcare organizations struggle with disconnected data across coding, CDI, compliance, auditing, and revenue cycle teams. How important is breaking down those silos to improving financial performance?
Organizations that achieve strong revenue integrity outcomes do so by combining a scalable technology platform with a coordinated, cross-functional program spanning billing compliance, coding, and revenue cycle operations. They foster knowledge sharing, monitor meaningful KPIs, and drive measurable progress toward three core objectives: optimal reimbursement, regulatory compliance, and operational efficiency.
Rather than treating revenue integrity as a short-term, transactional effort focused solely on getting claims paid, leading organizations take a broader view. They address the underlying process and data issues that create revenue leakage and compliance risks across the revenue cycle, ensuring those challenges are resolved permanently rather than repeatedly managed.
Effective cross-functional initiatives often require a clear strategic charter, actionable KPIs, strong change management, and executive sponsorship to overcome departmental silos and organizational politics. This is where leadership plays a critical role by establishing a unified revenue integrity vision and aligning teams across the enterprise to work collaboratively toward shared goals.
If you were advising a health system CFO making technology investments today, what capabilities would you consider essential for protecting both revenue and compliance?
I would advise CFOs to consider 1) deploying a data driven, proactive strategy to documentation, coding accuracy and denials management; 2) paying attention to payer behavior in real time to understand how best to adapt their RCM strategies; 3) keeping an open mind when reimagining your business processes and upskilling talent while deploying AI; and 4) investing in AI risk and governance as a mandatory function
Looking ahead five years, what do you think revenue integrity will look like, and what changes do you expect will have the biggest impact on healthcare organizations?
As healthcare organizations deploy AI over the next five years, there will be lots of learning from successes and losses. Every health system hopes AI will automate administrative tasks, eliminate waste, and lower cost-to-collect so they can reinvest profits in patient access and care. Various timelines and expectations must be met over the next decade. I am optimistic that there will be many great success stories at the end for others to scale. The current health system infrastructure has been built over decades; it’s unfair to expect AI to perform its magic quickly. I will leave it at that.
Finally, what excites you most about the future of healthcare revenue cycle management and MDaudit’s role in helping organizations navigate that future?
At MDaudit, we are pragmatic about the use of AI in healthcare RCM. We’ve spent a lot of time thinking through which workflows and end users we can impact by leveraging AI. For every idea we accept, we reject 5-10 others.
Our customers work with us as co-creators to develop real products with AI functionality that work in their operational setting. They are the first to tell us what we tried just didn’t work.
We have been embedding Meaningful AI into the MDaudit platform for nearly three years to generate real value. In the last 12 months alone, we’ve generated more than $400 million in value for our customers associated with revenue retention, risk mitigation, and labor productivity.
We see so many future opportunities on our roadmap to continue delivering AI-enabled business value. Our whole organization is both excited about the potential of AI and aware of its risks. Luckily, our customers keep us grounded.
To help healthcare organizations fight these headwinds, MDaudit, an award-winning continuous risk-monitoring platform, offers a suite of revenue integrity solutions grounded in its standard of Meaningful AI, in which technology is judged by its return on investment (ROI), the friction it removes, and whether a human remains firmly in control of every decision.
The newest expression of this standard is Auditor Assist, an AI-powered companion that helps auditors review more cases more quickly and with greater rigor — without surrendering the judgment auditors are trained to exercise.
Meaningful AI: A Standard, Not a Slogan
MDaudit’s Meaningful AI framework is grounded in independence and accuracy and rests on three commitments: a clear line to ROI, a focus on stripping out process friction rather than adding it, and a non-negotiable human-in-the-loop on every determination. The standard exists because the stakes keep rising. Payer audit volume and dollars at risk continue to climb across nearly every audit type, and coding accuracy remains the single largest driver of industry-wide industry wide. MDaudit’s own analysis of 2026 payer audit activity found that coding errors account for nearly seven in 10 completed denials.
“Meaningful AI means we ask one question before anything ships: does this change the outcome?” said MDaudit CEO Ritesh Ramesh. “ROI, less friction, a human who keeps the final say; that’s the test every release must pass. Auditor Assist is the latest to do so.”
It is a standard MDaudit has long applied to its suite of solutions. For example, Payer Audit Workflow uses AI to extract and organize information needed for Additional Documentation Requests (ADRs), helping customers retain more than $375 million in revenue in 2025 by responding to payer requests faster and more efficiently. AI Assist gives users at every level of an organization, including the C-suite, the ability to ask questions in plain English and get answers instantly, without relying on report writers or technical interpreters. Auditor Assist is the newest addition to that lineup.
The Latest Example: Auditor Assist
Auditor Assist leverages medical records and coded claims to assess coding integrity, and learns from every auditor decision, while keeping the experienced auditor firmly in control of the final call. Built as the auditor’s AI partner for accurate, defensible coding, it sits between provider and payer AI, serving as a defensibility layer over machine-coded claims.
Every AI output is sourced and traceable, built to hold up under payer and regulatory scrutiny, and the auditor decides what happens next — always.
“Auditor Assist is Meaningful AI in its purest form,” said Ramesh. “It does not replace the auditor’s judgment; it sharpens it. The auditor still makes the call. What changes is how much ground they can cover, and how much evidence stands behind every decision they make.”
The result is a shift in the economics of auditing. Instead of sampling a small fraction of claims reactively, audit teams can review more cases earlier and support each finding with evidence, turning auditing from a constrained, manual function into a scalable, proactive program. Even the smallest teams can work beyond their headcount and help ensure their organization is paid accurately and fully for the work it performs.
“We’ve been an AI-powered platform since before the label was trendy,” said Ramesh. “Auditor Assist doesn’t change our direction; it confirms it. Every time we expand our suite of continuous risk monitoring solutions, the strategy is the same: More ROI, less friction, a human in the loop.”
More information on Auditor Assist can be accessed here.
The rate of payer audits accelerated in 2025, with hospital inpatient and outpatient average denial amounts that increased by 14% and 12%, respectively. Denial volumes were also up overall, led by a nearly fivefold increase in Request for Information (RFI) and medical necessity denials for Medicare Advantage plans.
The total at-risk amounts, number of claims and average amount per claim increased by 30% in payer audits. Denials related to outpatient coding increased by 26%. These trends send a clear signal to providers that successfully navigating today’s complex financial and regulatory landscape requires prioritizing billing compliance, coding integrity, robust denial prevention strategies, and redefining revenue integrity to ensure sustainability.
These were among the key findings of the 2025 MDaudit Annual Benchmark Report released today by 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. The central theme of this year’s report is the evolution of revenue integrity from a defensive stance to a proactive discipline that unites charge capture, coding, billing compliance, and denials management within a connected, data-driven framework.
Ritesh Ramesh
“Reactively fixing denials after they occur or addressing compliance findings after the fact is costly and unsustainable,” said Ritesh Ramesh, CEO, MDaudit. “This year’s Benchmark Report clearly demonstrates the urgency behind adopting a unified approach to billing compliance, coding integrity, and denial prevention wherein data intelligence and automation are shared across revenue functions, allowing finance leaders to efficiently shift from managing crises to protecting revenue with foresight and confidence.”
Key Takeaways
The new Benchmark Report reveals several trends provider organizations should act on now, and identifies where to focus their attention, investments, and process improvements to safeguard income and manage risk as they enter 2026.
1. Rising Denial Rates
The upward trajectory of denial volumes and amounts signals the need for providers to sharpen denial prevention strategies. In 2025, the average denied amount for hospitals rose from $4,730 in 2024 to $5,390 (14%) in outpatient settings, and from $504 to $565 (12%) in inpatient settings. This includes a 70% increase in average denied amounts from RFI and medical necessity denials across all settings. Telehealth-related denials were up 84% in 2025, due primarily to missing information, errors in claim submission, non-covered charges, or duplicate claims
To reverse these trends, provider organizations need to take steps to monitor denial trends by payer, setting, and claim type and reinforce root-cause analysis of denials, such as coding, documentation, and charge capture. Investing in early-warning tools and audit workflows that catch high-risk claims before submission is also recommended.
2. Payer Audits Increase
External payer audits surged again in 2025, with total at-risk amounts and audit cases per customer rising by 30%, and the average amount at risk per claim growing 18%. Of the top payer types, 45% of the at-risk amount was driven by commercial payers, while Medicare and Medicaid accounted for 28%. The average at-risk amount for a payer audit in a hospital setting was approximately $17,000, whereas the average at-risk amount at a professional setting was $1,172.
Intensified payer scrutiny necessitates faster response times, stronger documentation, and proactive risk management. This can be accomplished by mapping current audit exposure by payer, audit type, and service line, and prioritizing the highest dollar-at-risk claims for review and remediation. Additionally, providers should build robust workflows to manage audit requests, capture documentation, and respond within deadlines to retain revenues.
3. Outpatient Coding Worsens
Outpatient coding-related denials increased in 2025, rising 26% after a 126% spike in 2024, signaling their critical vulnerability. To slow this escalation, providers must begin treating coding integrity as a foundational risk area rather than an afterthought. This includes conducting targeted risk-based coding audits in outpatient service lines, focusing on training, review, and oversight of outpatient coding workflows, and ensuring that coding tools, documentation support, and coder oversight align with the heightened scrutiny, governance, and human oversight requirements.
4. Technology Unlocks Outcomes
There was a silver lining in the 2025 Benchmark Report: technology- and data-driven approaches are gaining traction and delivering measurable improvements, and revenue integrity teams are increasingly adopting data- and AI-driven approaches to unlock revenue opportunities and mitigate risk. Risk-based audits within the MDaudit platform increased by 25%, and pre-bill audits increased by 30%.
“Provider organizations that leverage data-driven platforms and deploy real-time, continuous risk monitoring can stay ahead of payers by better understanding real-time billing, coding, and payment trends,” said Ramesh. “This allows them to take proactive action to educate providers and coders while addressing other issues.”
Looking Ahead
Technology-including the responsible integration of artificial intelligence (AI) and real-time performance data shared across multiple functions-will continue to play an outsized role in driving competitive advantage and assuring financial resiliency in the year ahead. Integration of autonomous coding, predictive audit sampling, and workflow automation is expected to expand across the industry. Meanwhile:
Continuous risk monitoring tools will reduce payer audit response times by half and maintain tighter oversight of at-risk revenue through automation and centralized audit tracking.
Pairing automation with intelligent human oversight will drive measurable gains in accuracy, compliance, and speed.
AI-powered revenue integrity platforms will result in exponential lifts in operational efficiency and denial overturn success rates.
“The 2025 benchmark data makes clear that the margin for error in billing, coding, and audits has shrunk, and technology is becoming a differentiator,” said Ramesh. “Organizations that adopt analytics, proactive audit/pre-bill workflows, and coding integrity will have a distinct advantage.”
About the Report
The MDaudit 2025 Annual Benchmark Report is a comprehensive examination of real-world data representing the first three quarters of 2025, from a network of more than 1.2 million providers and over 4,500 facilities across 40+ states.
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, 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.
The rate of payer audits accelerated in 2025, with hospital inpatient and outpatient average denial amounts that increased by 14% and 12%, respectively. Denial volumes were also up overall, led by a nearly fivefold increase in Request for Information (RFI) and medical necessity denials for Medicare Advantage plans.
MDaudit