Tag: #RevenueCycleManagement

Orthopedic Prior Authorization Denials Are Rising — Here’s What the Data Shows

Posted on by Reviora Healthcare LLC in Uncategorized

Reviora Healthcare LLC | Guaranteed Revenue Partner

Every denied prior authorization is a surgery pushed back, a patient who may not come back, and revenue your practice already staffed for but can’t collect. If that cycle feels like it’s happening more often this year, it’s not your imagination — it’s showing up in the national data too.

Is Prior Authorization Denial Actually Getting Worse?

Yes, and physicians are saying so directly. Three in four physicians (74%) report that denials have increased over the past five years, per the AMA’s 2025 Prior Authorization Physician Survey. On the request side, 86% of medical group leaders told MGMA in a 2025 MGMA Stat poll that prior authorization requirements themselves have increased in the past year — not just denials, but the volume of procedures now requiring approval before you can even schedule them.

For orthopedic practices specifically, this matters more than most specialties. Surgical and imaging-heavy care — the backbone of orthopedic volume — sits squarely in the outpatient category where payers have been tightening review criteria.

What’s Actually Driving the Increase?

Two forces are colliding: more procedures requiring authorization, and less clinical rigor behind the denials themselves. Nearly one in three physicians (32%) report that PA requests are often or always denied, according to the AMA’s 2025 survey. At the same time, only 24% of physicians say medical necessity denials are consistently reviewed by an appropriately qualified clinician, despite payer commitments to do exactly that.

That gap — high denial volume paired with thin clinical review — is why appeals often succeed when practices have the bandwidth to pursue them. The problem is most practices don’t.

What Does This Actually Cost an Orthopedic Practice?

Time, first — and time is money in a fee-for-service model. Physicians complete an average of 40 prior authorizations per week, per the AMA’s 2025 survey, with the 2024 survey putting the associated staff time at roughly 13 hours weekly. That’s a full administrative shift, every week, before a single claim is even submitted.

Then there’s the claims side. Kodiak Solutions’ Revenue Cycle Analytics, which tracks financial data from more than 1,850 hospitals and 250,000 physicians nationwide, found initial prior authorization and precertification denials on outpatient claims rose 16% from 2021 to 2023 — and inpatient claims rose 26% in the same window. Outpatient is where the bulk of orthopedic scheduling lives: imaging, injections, scoped procedures, and elective surgery.

MGMA’s 2026 Regulatory Burden Report adds another layer: 92% of surveyed medical group practices said they’ve had to hire or reassign staff specifically to keep up with prior authorization volume. That’s headcount spent chasing approvals instead of growing the practice.

What Can Practice Owners Actually Do About It?

Start by separating what you can control from what you can’t. You can’t control payer policy. You can control how tightly your intake, coding, and submission process is run before a request ever reaches a payer — because most denials on the front end are procedural, not clinical.

This is where credentialed human oversight matters more than software alone. Automated PA tools can flag missing fields; they can’t catch a payer’s shifting medical-necessity criteria or build the appeal that gets a legitimate case overturned. That takes a specialist who knows the payer, the CPT code, and the clinical documentation standard cold.

That’s the model behind Reviora Healthcare LLC’s approach: Expert-Led Technology, where credentialed specialists — not algorithms — drive every claims and authorization decision, with technology supporting their judgment rather than replacing it. Our orthopedic RCM work is governed by a Managed Outcomes Agreement (MOA) — a written, contractual performance agreement built around specific benchmarks — backed by a Benchmark Recovery Protocol that triggers a root-cause audit and corrective action plan if performance slips two months in a row. It’s accountability built into the contract, not a promise made in a sales call.

If your denial rate has crept up and you’re not sure whether it’s payer behavior or something fixable in your own workflow, that’s worth a real conversation. Book a free 30-minute consultation and we’ll walk through what your numbers are actually telling you.

Related reading: Orthopedic RCM Services | Claims Submission & Denial Management | The Reviora Guarantee

FAQ

Why are prior authorization denials going up for orthopedic practices? Payers have expanded which procedures require authorization while clinical review of denials has grown thinner — only 24% of physicians report denials are consistently reviewed by a qualified clinician, per AMA’s 2025 survey.

How much staff time does prior authorization actually take? Physicians complete an average of 40 PA requests weekly, with roughly 13 hours of associated staff time reported in AMA’s Prior Authorization Physician Survey data.

Are prior authorization denial rates the same across all insurers? No. KFF’s 2025 analysis of standard PA requests found denial rates ranging from 12% to 18% depending on the market segment (Medicare Advantage, Medicaid managed care, and ACA Marketplace).

What can a practice do to reduce denials without adding staff? Tightening front-end intake, coding accuracy, and documentation before submission catches most procedural denials before they happen — which is where a specialist-led RCM partner focuses first.

References

Why Your Practice’s Claim Denial Rate Is Climbing in 2026 — And What the HFMA Benchmark Actually Means

Posted on by Reviora Healthcare LLC in Uncategorized

Reviora Healthcare LLC | Guaranteed Revenue Partner

If your billing team feels like they’re fighting more claims than they used to, they are. It’s not your coders getting sloppier — it’s the rules changing faster than most practices can track, and every denied claim is 30-60 days of cash flow you were counting on.

Here’s what’s actually happening, and where your numbers should sit.

Why Is My Denial Rate Going Up in 2026?

Three things are converging at once, and none of them are your billing team’s fault. Payers have tightened prior authorization enforcement, coding edit tables have changed, and adjudication software is flagging claims that would have sailed through two years ago.

This isn’t a perception problem. A recent MGMA Stat poll found that 60% of medical group leaders reported an increase in their practice’s claim denial rate — and only 11% had managed to bring their rate back down. That gap is the real story: most practices know denials are rising, but few have a structured process to reverse it.

Separately, MGMA’s benchmarking research on denials and appeals found that more than half of healthcare organizations now report denial rates exceeding 10% — double the top of HFMA’s acceptable range. Add in AMA’s 2024 Prior Authorization Physician Survey, which found physicians and staff spend an average of 13 hours per week per physician just processing authorization requests, and it’s clear: the administrative load behind every clean claim has gone up, even when nothing in your practice changed.

What Does the HFMA Benchmark Actually Say?

HFMA — the industry’s standard-setting body for revenue cycle metrics — considers a denial rate of 5% to 10% acceptable, with anything under 5% considered optimal performance. That’s the line, not a moving target and not a sales pitch. It’s the same MAP Keys framework hospitals, health systems, and physician groups are all measured against.

For context on where the industry actually sits: revenue cycle data from Kodiak Solutions, drawn from more than 2,100 hospitals and 300,000 physicians, shows the average initial denial rate climbed to 11.8% in 2024 — already above HFMA’s acceptable ceiling before 2025 and 2026 pressures compounded it further. If your practice is tracking anywhere close to that number, you’re not an outlier. You’re the norm right now, which is exactly the problem.

What Is This Actually Costing You?

Every denied claim doesn’t just delay payment — it consumes staff hours you’re already short on. Between prior authorization volume and appeals, front-office and billing staff are spending time on rework instead of revenue-generating work, and that labor cost rarely shows up on the P&L line labeled “denials.”

The slower cost is Days in AR creeping upward, month over month, until it’s normalized. A denial rate that sits at 10-12% doesn’t just cost the denied dollars — it drags down every other cash flow metric attached to it.

How Do You Get Back Under Benchmark?

his is where most practices try to solve a systems problem with more staff hours, and it doesn’t hold. The fix isn’t working denials harder after they happen — it’s closing the gaps that create them before a claim is ever submitted.

At Reviora, this is built into how we operate, not something we bolt on. Our team runs on Expert-Led Technology — credentialed billing and coding specialists lead every claim decision, using technology as a tool to catch what a payer will flag, not as a replacement for judgment. Every client engagement runs under a Managed Outcomes Agreement (MOA) — a written, contractual performance agreement built around defined benchmarks, including a denial rate target under 5%, matching HFMA’s optimal range rather than just its acceptable floor.

If a benchmark is missed two months in a row, our Benchmark Recovery Protocol (BRP) activates automatically — see What Happens If We Miss — a defined accountability process, not a vague promise to “look into it.”

If denial management specifically is your pain point, our Claims Submission & Denial Management page walks through how we structure that work day to day.

If your denial rate has been climbing and you’re not sure why, a second set of eyes on your claims data is usually the fastest way to find out. Book a free 30-minute consultation and we’ll walk through where your practice actually stands against benchmark. Not ready to talk yet? See what to expect from a first conversation before you reach out.

FAQ

What is a good claim denial rate for a medical practice? Per HFMA’s MAP Keys benchmark, 5-10% is considered acceptable, and under 5% is optimal. Above 10% signals a process gap worth investigating.

Why are claim denials increasing in 2026? Tighter prior authorization enforcement, updated payer coding edits, and more aggressive automated claims review are the main drivers, per MGMA and AMA survey data.

How do I lower my practice’s denial rate? Focus on the front end — eligibility verification, authorization matching, and clean coding before submission — since most denials are prevented, not appealed. A structured denial management process outperforms after-the-fact appeals.

Is a 10% denial rate bad? Yes — it’s above HFMA’s acceptable ceiling of 10% and roughly in line with the national average AHA reported for 2024 (11.8%), meaning a 10%+ rate puts a practice at or below where the broader industry already struggles.

Reference