The Albany Gazette - MDaudit's 2025 Benchmark Report Reveals Ongoing Acceleration of Payer Audits, Troubling Rise in Denials and Outpatient Coding Issues

WELLESLEY, MA / ACCESS Newswire / November 18, 2025 / 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.

"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.

Download the MDaudit 2025Annual Benchmark Report.

About MDaudit

MDaudit is an award-winning AI-enhanced continuous risk monitoring platform and trusted revenue integrity partner to healthcare organizations nationwide. Working in the background, we deliver the insights you need to face the future with confidence. Our sustainable solution enables teams to achieve more with less, driving an efficient and compliant revenue cycle in a rapidly evolving environment. Learn more at www.mdaudit.com

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Media Contact:

Rachel Driskell | [email protected]

SOURCE: MDaudit

View the original press release on ACCESS Newswire

(M.Scott--TAG)