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REVENUE CYCLE AUDIT SYSTEM — ACTIVE

YOUR REVENUE CYCLE HAS A $2.4M LEAK

41% of providers now see denial rates above 10%. AR days are growing 5.2% year-over-year.
Every aging bucket is a claim that can still be won.

11.81%AVG INITIAL DENIAL RATE 2024
>50%APPEALED DENIALS REVERSED
$57.23ADMIN COST PER DENIED CLAIM
ADJ-SYS / REV-CYCLE-AUDIT / v4.2.1
2026-05-30 06:14:33 UTC
◈INITIAL DENIAL RATE UP 2.4% IN 2024◈AR > 90 DAYS NOW 35%+ INDUSTRY-WIDE◈$130B MEDICARE/MEDICAID UNDERPAYMENTS IN 2023◈MA DENIAL RATE: 15.7% — COMMERCIAL: 13.9%◈63% OF PROVIDERS FACE RCM STAFFING SHORTAGES◈ONLY 14% USE AI TO REDUCE DENIALS◈$17,000 AVG AT-RISK AMOUNT PER HOSPITAL CLAIM◈85% OF AVOIDABLE DENIALS PREVENTABLE WITH AUTOMATION◈INITIAL DENIAL RATE UP 2.4% IN 2024◈AR > 90 DAYS NOW 35%+ INDUSTRY-WIDE◈$130B MEDICARE/MEDICAID UNDERPAYMENTS IN 2023◈MA DENIAL RATE: 15.7% — COMMERCIAL: 13.9%◈63% OF PROVIDERS FACE RCM STAFFING SHORTAGES◈ONLY 14% USE AI TO REDUCE DENIALS◈$17,000 AVG AT-RISK AMOUNT PER HOSPITAL CLAIM◈85% OF AVOIDABLE DENIALS PREVENTABLE WITH AUTOMATION
INTERNAL AUDIT — FINDING SET 01 / 04

THE DENIAL ECONOMY
BY THE NUMBERS

FINDING 1.1 — DENIAL RATE BY PAYER
Medicare AdvantageELEVATED15.7%
Commercial PlansELEVATED13.9%
Medicaid Managed Care12.4%
Industry Average11.81%
Traditional Medicare8.2%
Blue Cross Blue Shield11.1%
▲ YOUR LIKELY RANGE: 10–16% — HIGHLIGHTED ABOVE
FINDING 1.2 — RECOVERY TIMELINE
90
DAYS BEFORE
→
90
DAYS WITH ADJUDICATE
FINDING 1.3 — AR AGING CRISIS
35%+

Of AR now sits beyond 90 days — up from the 20% benchmark that was once considered acceptable. Across 2,100 facilities, no one is meeting the old standard.

ADMIN COST
$57.23

Per denied claim in 2023, up from $43.84 in 2022. Each denial costs more to fight every year.

STAFFING CRISIS
63%

Of providers report RCM staffing shortages. 40-biller teams still can't keep denial rates below 12%.

FINDING 1.4 — AI ADOPTION GAP
Believe AI can improve claims67%
Currently use AI to reduce denials14%
Consider RCM optimization critical95%
◈ 83% GAP BETWEEN INTENT AND ACTION
FINDING 1.5 — SYSTEM-LEVEL EXPOSURE

Hospitals lose an average of 4.8% of net revenue to denials. For a $500M system, that's $24M walking out the door every year.

SOURCE: HFMA PULSE SURVEY
ADVISORY BOARD 2024
AHA COST OF CARING 2025
INTERNAL AUDIT — FINDING SET 02 / 04

THE APPEALS THAT
CHANGED THE NUMBERS

Three redacted excerpts from appeal letters that reversed six-figure denials. The language is precise. The citations are specific. The results are on record.

RECOVERY WINDOW:
DAY 0
ADJUDICATE IDENTIFIES & FILES
DAY 22 AVG
CASH POSTED
ADJ-2024-0847Medicare Advantage — [PAYER REDACTED]Medical Necessity — Inpatient Admission
FULLY REVERSED$184,20019d
REDACTED

"...Per InterQual 2024 criteria, the patient's presentation with [REDACTED] and documented [REDACTED] meets the threshold for inpatient level of care. The payer's reliance on [REDACTED] criteria fails to account for the attending physician's documented clinical judgment regarding... The denial letter does not cite specific clinical criteria that were not met, constituting a procedural deficiency under [REDACTED] regulations..."

ADJ-2024-1203Commercial PPO — [PAYER REDACTED]Prior Authorization — Retroactive Denial
FULLY REVERSED$267,45014d
REDACTED

"...The authorization number [REDACTED] was obtained on [REDACTED] and remains valid per the payer's own records, accessible via the provider portal as of [REDACTED]. The retroactive denial citing 'authorization not obtained' is factually incorrect and constitutes a bad faith claims practice under state statute [REDACTED]. Attached: authorization confirmation, portal screenshot timestamped [REDACTED], and call recording reference [REDACTED]..."

ADJ-2025-0312Medicare Advantage — [PAYER REDACTED]Underpayment — Contract Rate Dispute
BALANCE REMITTED$412,80028d
REDACTED

"...Per Schedule [REDACTED] of the executed provider agreement dated [REDACTED], the applicable rate for CPT [REDACTED] is [REDACTED]% of [REDACTED]. The remittance advice reflects payment at [REDACTED]%, a shortfall of $[REDACTED] per unit. Over the audit period [REDACTED] through [REDACTED], this systematic underpayment totals $[REDACTED] across [REDACTED] claims. We request immediate remittance of the balance and a prospective rate correction..."

◈All identifying information redacted per HIPAA. Amounts represent actual recovered revenue. Over 50% of appealed denials are reversed — yet most providers lack the resources to appeal consistently.
INTERNAL AUDIT — FINDING SET 03 / 04

WHAT RECOVERY
ACTUALLY LOOKS LIKE

HOSPITAL SYSTEM
$9M
Regional Health System

decrease in annual denials within 18 months of deployment — achieved through predictive denial prevention and automated appeal workflows.

PHYSICIAN GROUP
90%+
Pain Management Group

of revenue at risk retained after payer audits targeted high-frequency CPT codes. Contract underpayments identified and recovered.

MULTI-FACILITY
$10M
Integrated Health System

in revenue risk mitigated through proactive revenue integrity monitoring across 14 facilities and 6 payer contracts.

"We had 47 billers and still couldn't get below 12% denial rate. Adjudicate identified $3.2M in recoverable denials in the first 30 days — most of it buried in MA claims we'd written off."
CH
Christine Holloway
VP Revenue Cycle, Regional Medical Center
"The appeal letters alone justified the contract. Our team was spending 6 hours per appeal. Adjudicate files in minutes with citations our payer can't argue with. We reversed $1.9M in the first quarter."
DR
David Reinholt
CFO, Midwest Physician Partners
22 days
AVG RECOVERY TIMELINE
>50%
APPEAL REVERSAL RATE
$1.8M
AVG YEAR-ONE RECOVERY
30%
PRODUCTIVITY LIFT
INTERNAL AUDIT — FINDING SET 04 / 04
ROI CALCULATOR + REVENUE DIAGNOSIS REQUEST

RUN YOUR
REVENUE
DIAGNOSIS

Not a demo. Not a consultation. A custom revenue gap analysis delivered in 48 hours — showing exactly where your money is buried and what it takes to recover it.

WHAT YOUR ANALYSIS INCLUDES:
◈Denial rate benchmark vs. your payer mix
◈Estimated recoverable AR by bucket
◈Top 3 denial categories by dollar value
◈Underpayment exposure estimate
◈Custom recovery timeline projection