MDaudit’s 2025 Benchmark Report Reveals Ongoing Acceleration of Payer Audits, Troubling Rise in Denials and Outpatient Coding Points

The speed of payer audits accelerated in 2025, with hospital inpatient and outpatient common denial quantities that elevated by 14% and 12%, respectively. Denial volumes had been additionally up general, led by a virtually fivefold enhance in Request for Data (RFI) and medical necessity denials for Medicare Benefit plans.

The overall at-risk quantities, variety of claims and common quantity per declare elevated by 30% in payer audits. Denials associated to outpatient coding elevated by 26%. These traits ship a transparent sign to suppliers that efficiently navigating immediately’s advanced monetary and regulatory panorama requires prioritizing billing compliance, coding integrity, sturdy denial prevention methods, and redefining income integrity to make sure sustainability.

These had been among the many key findings of the 2025 MDaudit Annual Benchmark Report launched immediately by MDaudit, an award-winning cloud-based steady threat monitoring platform for RCM that allows the nation’s premier healthcare organizations to attenuate billing dangers and maximize revenues. The central theme of this yr’s report is the evolution of income integrity from a defensive stance to a proactive self-discipline that unites cost seize, coding, billing compliance, and denials administration inside a linked, data-driven framework.

“Reactively fixing denials after they happen or addressing compliance findings after the very fact is expensive and unsustainable,” stated Ritesh Ramesh, CEO, MDaudit. “This yr’s Benchmark Report clearly demonstrates the urgency behind adopting a unified method to billing compliance, coding integrity, and denial prevention whereby knowledge intelligence and automation are shared throughout income capabilities, permitting finance leaders to effectively shift from managing crises to defending income with foresight and confidence.”

Key Takeaways

The brand new Benchmark Report reveals a number of traits supplier organizations ought to act on now, and identifies the place to focus their consideration, investments, and course of enhancements to safeguard earnings and handle threat as they enter 2026.

1. Rising Denial Charges

The upward trajectory of denial volumes and quantities indicators the necessity for suppliers to sharpen denial prevention methods. In 2025, the typical denied quantity 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 features a 70% enhance in common denied quantities from RFI and medical necessity denials throughout all settings. Telehealth-related denials had been up 84% in 2025, due primarily to lacking info, errors in declare submission, non-covered fees, or duplicate claims

To reverse these traits, supplier organizations have to take steps to monitor denial traits by payer, setting, and declare kind and reinforce root-cause evaluation of denials, comparable to coding, documentation, and cost seize. Investing in early-warning instruments and audit workflows that catch high-risk claims earlier than submission can be beneficial.

2. Payer Audits Improve

Exterior payer audits surged once more in 2025, with complete at-risk quantities and audit circumstances per buyer rising by 30%, and the typical quantity in danger per declare rising 18%. Of the highest payer varieties, 45% of the at-risk quantity was pushed by business payers, whereas Medicare and Medicaid accounted for 28%. The typical at-risk quantity for a payer audit in a hospital setting was roughly $17,000, whereas the typical at-risk quantity at knowledgeable setting was $1,172.

Intensified payer scrutiny necessitates quicker response instances, stronger documentation, and proactive threat administration. This may be achieved by mapping present audit publicity by payer, audit kind, and repair line, and prioritizing the highest dollar-at-risk claims for evaluation and remediation. Moreover, suppliers ought to construct sturdy workflows to handle audit requests, seize documentation, and reply inside deadlines to retain revenues.

3. Outpatient Coding Worsens

Outpatient coding-related denials elevated in 2025, rising 26% after a 126% spike in 2024, signaling their vital vulnerability. To sluggish this escalation, suppliers should start treating coding integrity as a foundational threat space quite than an afterthought. This contains conducting focused risk-based coding audits in outpatient service strains, specializing in coaching, evaluation, and oversight of outpatient coding workflows, and making certain that coding instruments, documentation assist, and coder oversight align with the heightened scrutiny, governance, and human oversight necessities.

4. Expertise Unlocks Outcomes

There was a silver lining within the 2025 Benchmark Report: technology- and data-driven approaches are gaining traction and delivering measurable enhancements, and income integrity groups are more and more adopting data- and AI-driven approaches to unlock income alternatives and mitigate threat. Threat-based audits throughout the MDaudit platform elevated by 25%, and pre-bill audits elevated by 30%.

“Supplier organizations that leverage data-driven platforms and deploy real-time, steady threat monitoring can keep forward of payers by higher understanding real-time billing, coding, and cost traits,” stated Ramesh. “This permits them to take proactive motion to teach suppliers and coders whereas addressing different points.”

Wanting Forward

Expertise-including the accountable integration of synthetic intelligence (AI) and real-time efficiency knowledge shared throughout a number of functions-will proceed to play an outsized position in driving aggressive benefit and assuring monetary resiliency within the yr forward. Integration of autonomous coding, predictive audit sampling, and workflow automation is anticipated to broaden throughout the business. In the meantime:

• Steady threat monitoring instruments will scale back payer audit response instances by half and keep tighter oversight of at-risk income via automation and centralized audit monitoring.
• Pairing automation with clever human oversight will drive measurable good points in accuracy, compliance, and pace.
• AI-powered income integrity platforms will lead to exponential lifts in operational effectivity and denial overturn success charges.

“The 2025 benchmark knowledge makes clear that the margin for error in billing, coding, and audits has shrunk, and know-how is changing into a differentiator,” stated Ramesh. “Organizations that undertake analytics, proactive audit/pre-bill workflows, and coding integrity can have a definite benefit.”

In regards to the Report

The MDaudit 2025 Annual Benchmark Report is a complete examination of real-world knowledge representing the primary three quarters of 2025, from a community of greater than 1.2 million suppliers and over 4,500 amenities throughout 40+ states.

Obtain the MDaudit 2025Annual Benchmark Report.