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.
External audit volume more than doubled in 2024 over 2023-including higher rates of pre-payment audits-and total at-risk dollars increased fivefold to $11.2 million per MDaudit customer, impacting healthcare provider organizations’ cash flow and exposing them to higher potential denial rates.
Additionally, improvements in revenues and operating margins throughout 2024 were tempered by higher denial rates, including an increase in coding-related denials of more than 125% and in medical necessity-related denials of 75% for outpatient claims and 140% for inpatient claims. These trends highlight the pressing need to overhaul revenue cycle management (RCM) strategies in the coming year.
These were among the key findings of the 2024 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. Last year’s report forecast strong volumes for healthcare organizations, the impact of which was constrained by challenges related to controlling costs, improving margins, and seizing opportunities to generate new revenue streams-predictions that held true as operating margins improved by more than 4% against a surge in audits and denials.
Ritesh Ramesh
“Looking ahead to 2025, those same headwinds, along with new risks around timely reimbursement and cybersecurity costs, will impede continued progress toward financial stability,” said Ritesh Ramesh, CEO, MDaudit. “This backdrop of challenges elevates RCM transformation to a strategic imperative for health systems in 2025, with an emphasis on continuous monitoring of financial risk to enable proactive mitigation of issues before they impact operations.”
Payer Behavioral Shifts Send Audits Surging
An increase in external audit volume, coupled with an increase in the average denied amount per claim across professional (~4%), outpatient (~3%) and inpatient (7%) settings, exerted additional financial pressures on healthcare providers. This year also saw a trend in more pre-payment audits. Unlike traditional post-payment audits that can result in clawbacks, pre-payment audits increase denial risks and cause cash flow issues.
Payers also stepped up clinical documentation scrutiny, sending audits surging by 100% over 2023 levels and contributing to a 3-year increase in clinical denials of 51%. To counter this trend, providers must focus on high-value services and ensure that clinical documentation improvement (CDI), billing, coding, and RCM programs are tightly coupled to implement a closed feedback loop from the backend to the mid-cycle to drive efficiencies.
Additionally, the Centers for Medicare and Medicaid Services (CMS) has put Medicare Advantage (MA) plans under the microscope as it continues ferreting out fraud and abuse-efforts that led to a 72% rise in hierarchical condition category (HCC) and Risk Adjustment audits and a 51% increase in total denial amounts for MA plans.
This heightened scrutiny, coupled with more strident authorization requirements and higher denial rates, have many providers rethinking participation in MA plans. At minimum, billing compliance and coding teams should be focused on eliminating improper practices that will lead to heavy fines and penalties. This is particularly critical considering MDaudit findings that more than 25% of providers on average failed audits across both professional (33%) and hospital (23%) care settings.
MDaudit, an award-winning provider of technologies and analytics tools that enable premier healthcare organizations to minimize billing risk and maximize revenues, announced today it has elevated the artificial intelligence (AI) and automation capabilities of its industry leading billing compliance and revenue integrity platform with the addition of Insights.ai and SmartScan.ai.
A Generative AI tool, Insights.ai democratizes faster insights in response to natural language questions while SmartScan.ai leverages AI to automate key aspects of the external audit workflow process to efficiently manage payer audits. The MDaudit platform is used for compliance and revenue integrity outcomes by more than 70 of the nation’s top 100 health systems with $1 billion in net patient revenue.
The MDaudit enhancements come at a time when federal and commercial payers are ratcheting up audits to identify and claw back billions in improper payments. Consider that the U.S. Department of Justice (DOJ) collected more than $1.7 billion in improper payments in fiscal year 2022. Further, the Office of the Inspector General (OIG) identified more than $200 million in expected audit recoveries and over $277 million in questioned costs in its 2023 Semi-Annual Report to Congress.
The Centers for Medicare & Medicaid Services (CMS) is also expected to claw back $4.7 billion from Medicare Advantage plans over the next decade thanks to recent adjustments to its risk adjustment data validation (RADV) program.
Ritesh Ramesh
“AI has the potential to transform healthcare and drive sustainable outcomes, but only if we maintain a relentless focus on the human experiences and operational processes it impacts rather than amplifying the technology itself. With this principle in mind, MDaudit continues to innovate and deliver AI solutions in the compliance and revenue integrity space,” said Ritesh Ramesh, CEO of MDaudit. “With Insights.ai and SmartScan.ai, our core mission is to enable healthcare organizations to retain their hard-earned revenue and reduce compliance risks by data-driven decision making and automation.”
Insights.ai makes it fast and easy to access the deep insights needed to drive strategic decision making. Whether it’s information about at-risk facilities, providers, coders or which DRG had the highest number of denials for medical necessity in a specific timeframe, Insights.ai democratizes insights across all levels of a healthcare organization – from billing compliance auditors, revenue cycle analysts, operational leadership and to the C-suite – by responding to questions posed in natural language with precisely the insights being sought. Insights delivered are then tightly integrated with actionable workflows to drive outcomes.
External payer audits quadrupled in volume in 2023, making timely responses more challenging than ever for resource-strapped healthcare organizations. Though patient volumes and surgeries have begun to recover from COVID-19 declines – with a 23% and 27% increase over 2022 – inflation, staffing shortages, reimbursement, and regulatory issues continue to jeopardize the financial health of healthcare organizations nationwide.
These were among the key findings of the 2023 MDaudit Annual Benchmark Report released today by MDaudit, an award-winning provider of technologies and analytic tools that enable the nation’s premier healthcare organizations to minimize billing risk and maximize revenues.
Ritesh Ramesh
“Increased complexity and reduced resources mean healthcare organizations are operating in an environment that demands flawless optimization for billing compliance, coding, and revenue integrity capabilities,” said Ritesh Ramesh, CEO of MDaudit. “Our analysis reveals the urgency for healthcare systems to stay ahead of the curve by harnessing digital initiatives and advanced technologies, including AI, machine learning, and analytics, to proactively manage compliance and revenue risks.”
Beyond technology, healthcare leaders must break down the silos between teams to create cross-functional/departmental synergies and manage change to stay operationally efficient. This will be imperative for growth and profitability going into 2024.
Shrinking Teams Face Growing Compliance and Revenue Integrity Challenges
Amidst nationwide healthcare staffing shortages, technology, automation, and analytics have emerged as critical catalysts for health system executives to drive change. Leaders are leveraging these tools to boost productivity, generate revenue, and control costs while compensating for reduced staffing levels. Managing denials and ensuring timely payments are important, but even more crucial is understanding and addressing the root causes of issues that start upstream with billing and coding practices in provider operations.
Across the MDaudit customer base, there was an increase in technology-driven productivity. Large auditing teams were able to accomplish 10% more in audit activities compared to 2022 with more or less the same resources.
Medicare Advantage plans were under constant scrutiny from the Federal government for compliance and overpayments. The data shows that these plans rejected 25% more in reimbursement dollars to providers this year versus 2022.
Telehealth remains a substantial contributor to compliance and revenue challenges. According to MDaudit data, telehealth volumes were flat relative to last year and an average of 30% of audits failed for services administered in a patient’s home or office. Proficiently coding and documenting these crucial charges is imperative for ensuring the ongoing success of patient care and favorable outcomes.
In 2023, external payer audits surged fourfold compared to 2022, often involving large audit documentation requests (ADRs). Mounting requests with tight deadlines and appeal timelines posed a significant risk of revenue loss and potential clawbacks, creating challenges for hospitals because of staffing issues.
Mitigating Denials to Protect Revenues
MDaudit’s findings emphasized the crucial role revenue integrity and billing compliance play in supporting the accurate and ethical capture and optimization of revenue for services rendered to patients. These teams are crucial for preserving financial stability, sustainability, and compliance, all while upholding the commitment to delivering high-quality patient care. Billing and coding are not about revenue alone; these cross-functional workflows directly influence patient experience and relationships, as well as a healthcare organization’s ability to grow.
Health systems are burdened by denials and increasing demand, underscoring the vital need for operational efficiency in billing, coding, and clinical documentation to enhance profitability.
The MDaudit analysis also found that:
Commercial payers are taking longer to respond to claims in 2023 vs 2022. Initial response times were 29 days (about six business weeks) for an outpatient claim and 35 days (about seven business weeks) for an inpatient claim.
MDaudit data for 2023 shows the value of commercial payers’ initial denials for professional claims has increased by 30% and by 5% for inpatient claims, as compared to 2022.
Medicare Part A and Part B rejected 16% of the claims initially submitted for outpatient services – the most profitable for healthcare organizations.
More than 60% of professional billing claim denials in 2023 were driven by documentation requests and eligibility concerns from payers.
“As we move into 2024, proactive actions and precision on billing compliance and revenue integrity outcomes are no longer optional. The healthcare landscape is evolving, affecting every facet of this industry,” said Ramesh. “New payer strategies and the integration of AI have intensified denials, payment delays, and claim scrutiny. How organizations and providers adapt and respond to these challenges will shape their long-term success.”
About the Report
The MDaudit Annual Benchmark Report equips compliance, HIM/coding, revenue integrity, and finance executives with industry insights, emerging trends, and data-driven information to help them take informed action and enhance outcomes for their organizations. The analysis in this report includes a comprehensive examination of data collected from a network of over 650,000 providers and more than 2,200 facilities that provide data to MDaudit for auditing, charge analysis, and denial assessment. This report encompasses insights from more than $5 billion in audited professional and hospital claims and denials by both commercial and government payers exceeding $150 billion.
MDaudit
