RCM Insights and Analysis

Revenue cycle management analysis covering denial rate trends, Medicare Advantage policy changes, prior authorization burden shifts, and billing regulation updates. Primary sources include CMS rulemaking, MGMA benchmark reports, HFMA performance data, AMA survey data, and federal agency enforcement actions.

Medicare Advantage denial trends: CMS Office of Inspector General reports document that Medicare Advantage plans deny medically necessary care at higher rates than traditional Medicare. The 2022 OIG report found that 13% of prior authorization denials in a sample of MA plans met Medicare coverage rules and should have been approved. CMS finalized new MA prior authorization rules effective January 2024 under 42 CFR §422.568, requiring plans to process standard prior auth requests within 7 calendar days (previously 14) and expedited requests within 72 hours.

Commercial denial trends: CARC CO-97 (payment adjusted because benefits are not covered or contractually adjusted) and CO-96 (non-covered charge) denials have increased as payers tighten clinical editing. CO-4 (service inconsistent with modifier) denials spike when CMS updates NCCI edits, typically twice annually. CO-29 (timely filing) denials remain disproportionately high at practices that lack automated claim status tracking for 30–90 day-old claims.

• RCM benchmarks
• Payer intelligence
• Community payer alerts