{ "publisher": "Actigy BPO", "type": "public-source synthesis", "checked_at": "2026-10-18", "observations": [ { "id": "ama_requests", "value": 40, "unit": "requests per week", "observation_period": "2025", "population": "1000 practicing physician respondents", "denominator": "per physician", "source_id": "AMA", "source_url": "https://www.globenewswire.com/news-release/2026/05/13/3294164/0/en/AMA-Survey-Prior-Authorization-Reform.html", "publication_date": "2026-05-13", "limitation": "Self-reported; not administrative transaction-level measurement." }, { "id": "ama_hours", "value": 13, "unit": "combined physician and staff hours per week", "observation_period": "2025", "population": "1000 practicing physician respondents", "denominator": "per physician", "source_id": "AMA", "source_url": "https://www.globenewswire.com/news-release/2026/05/13/3294164/0/en/AMA-Survey-Prior-Authorization-Reform.html", "publication_date": "2026-05-13", "limitation": "Self-reported; not administrative transaction-level measurement." }, { "id": "ama_dedicated_staff", "value": 40, "unit": "percent", "observation_period": "2025", "population": "1000 practicing physician respondents", "denominator": "physician respondents", "source_id": "AMA", "source_url": "https://www.globenewswire.com/news-release/2026/05/13/3294164/0/en/AMA-Survey-Prior-Authorization-Reform.html", "publication_date": "2026-05-13", "limitation": "Self-reported; not administrative transaction-level measurement." }, { "id": "ama_delays", "value": 95, "unit": "percent", "observation_period": "2025", "population": "1000 practicing physician respondents", "denominator": "physician respondents", "source_id": "AMA", "source_url": "https://www.globenewswire.com/news-release/2026/05/13/3294164/0/en/AMA-Survey-Prior-Authorization-Reform.html", "publication_date": "2026-05-13", "limitation": "Self-reported; not administrative transaction-level measurement." }, { "id": "ma24_volume", "value": 52.8, "unit": "million determinations", "observation_period": "2024", "population": "Medicare Advantage CMS contract reports", "denominator": "Medicare Advantage PA determinations", "source_id": "KFFPA24", "source_url": "https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/", "publication_date": "2026", "limitation": "Not directly comparable to 2025 public-insurer standard-request rates; appeals are a selected subset." }, { "id": "ma24_denials", "value": 7.7, "unit": "percent", "observation_period": "2024", "population": "Medicare Advantage CMS contract reports", "denominator": "determinations", "source_id": "KFFPA24", "source_url": "https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/", "publication_date": "2026", "limitation": "Not directly comparable to 2025 public-insurer standard-request rates; appeals are a selected subset." }, { "id": "ma24_appealed", "value": 11.5, "unit": "percent", "observation_period": "2024", "population": "Medicare Advantage CMS contract reports", "denominator": "denied requests", "source_id": "KFFPA24", "source_url": "https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/", "publication_date": "2026", "limitation": "Not directly comparable to 2025 public-insurer standard-request rates; appeals are a selected subset." }, { "id": "ma24_overturned", "value": 80.7, "unit": "percent", "observation_period": "2024", "population": "Medicare Advantage CMS contract reports", "denominator": "appealed requests", "source_id": "KFFPA24", "source_url": "https://www.kff.org/medicare/medicare-advantage-insurers-made-nearly-53-million-prior-authorization-determinations-in-2024/", "publication_date": "2026", "limitation": "Not directly comparable to 2025 public-insurer standard-request rates; appeals are a selected subset." }, { "id": "pa25_medicare_advantage_standard", "value": 12, "unit": "percent", "observation_period": "2025", "population": "Medicare Advantage insurers in KFF public-report analysis", "denominator": "standard requests", "source_id": "KFFPA25", "source_url": "https://www.kff.org/patient-consumer-protections/prior-authorization-metrics-provide-new-insights-into-insurer-practices-but-gaps-remain/", "publication_date": "2026-08-13", "limitation": "Source-reported market average for included insurers, not all US requests. Market averages are weighted by enrollment within each insurance market." }, { "id": "pa25_medicare_advantage_expedited", "value": 10, "unit": "percent", "observation_period": "2025", "population": "Medicare Advantage insurers in KFF public-report analysis", "denominator": "expedited requests", "source_id": "KFFPA25", "source_url": "https://www.kff.org/patient-consumer-protections/prior-authorization-metrics-provide-new-insights-into-insurer-practices-but-gaps-remain/", "publication_date": "2026-08-13", "limitation": "Source-reported market average for included insurers, not all US requests. Market averages are weighted by enrollment within each insurance market." }, { "id": "pa25_medicaid_managed_care_standard", "value": 14, "unit": "percent", "observation_period": "2025", "population": "Medicaid managed care insurers in KFF public-report analysis", "denominator": "standard requests", "source_id": "KFFPA25", "source_url": "https://www.kff.org/patient-consumer-protections/prior-authorization-metrics-provide-new-insights-into-insurer-practices-but-gaps-remain/", "publication_date": "2026-08-13", "limitation": "Source-reported market average for included insurers, not all US requests. Market averages are weighted by enrollment within each insurance market." }, { "id": "pa25_medicaid_managed_care_expedited", "value": 12, "unit": "percent", "observation_period": "2025", "population": "Medicaid managed care insurers in KFF public-report analysis", "denominator": "expedited requests", "source_id": "KFFPA25", "source_url": "https://www.kff.org/patient-consumer-protections/prior-authorization-metrics-provide-new-insights-into-insurer-practices-but-gaps-remain/", "publication_date": "2026-08-13", "limitation": "Source-reported market average for included insurers, not all US requests. Market averages are weighted by enrollment within each insurance market." }, { "id": "pa25_federal_aca_marketplace_standard", "value": 18, "unit": "percent", "observation_period": "2025", "population": "Federal ACA Marketplace insurers in KFF public-report analysis", "denominator": "standard requests", "source_id": "KFFPA25", "source_url": "https://www.kff.org/patient-consumer-protections/prior-authorization-metrics-provide-new-insights-into-insurer-practices-but-gaps-remain/", "publication_date": "2026-08-13", "limitation": "Source-reported market average for included insurers, not all US requests. Market averages are weighted by enrollment within each insurance market." }, { "id": "pa25_federal_aca_marketplace_expedited", "value": 16, "unit": "percent", "observation_period": "2025", "population": "Federal ACA Marketplace insurers in KFF public-report analysis", "denominator": "expedited requests", "source_id": "KFFPA25", "source_url": "https://www.kff.org/patient-consumer-protections/prior-authorization-metrics-provide-new-insights-into-insurer-practices-but-gaps-remain/", "publication_date": "2026-08-13", "limitation": "Source-reported market average for included insurers, not all US requests. Market averages are weighted by enrollment within each insurance market." }, { "id": "kff_burden", "value": 69, "unit": "percent", "observation_period": "January 2026", "population": "Insured adults in national poll", "denominator": "insured adult respondents", "source_id": "KFFPOLL", "source_url": "https://www.kff.org/public-opinion/kff-health-tracking-poll-prior-authorizations-rank-as-publics-biggest-burden-when-getting-health-care/", "publication_date": "2026-02-02", "limitation": "Self-reported burden, not a denial rate." }, { "id": "kff_chronic_burden", "value": 39, "unit": "percent", "observation_period": "January 2026", "population": "Insured adults with chronic conditions", "denominator": "respondents in subgroup", "source_id": "KFFPOLL", "source_url": "https://www.kff.org/public-opinion/kff-health-tracking-poll-prior-authorizations-rank-as-publics-biggest-burden-when-getting-health-care/", "publication_date": "2026-02-02", "limitation": "Prior authorization named the single biggest burden beyond cost." }, { "id": "mgma_initial", "value": [ 7, 8 ], "unit": "percent range", "observation_period": "Preceding four years as summarized July 2026", "population": "Medical practice benchmark commentary", "denominator": "first-submission claims", "source_id": "MGMA", "source_url": "https://www.mgma.com/mgma-stat/days-in-a/r-holds-steady-for-most-practices-but-payer-pressure-persists-in-2026", "publication_date": "2026-07-30", "limitation": "Public passage does not disclose detailed benchmark sample." }, { "id": "kodiak24_initial", "value": 11.81, "unit": "percent", "observation_period": "2024", "population": "Kodiak provider platform", "denominator": "initial claims", "source_id": "KODIAK24", "source_url": "https://www.businesswire.com/news/home/20250521892947/en/Rate-of-initial-denials-of-medical-insurance-claims-continued-to-rise-in-2024-Kodiak-Solutions-proprietary-data-show", "publication_date": "2025-05-21", "limitation": "Historical platform result, not a national 2026 rate." }, { "id": "kff24_in_network", "value": 19, "unit": "percent", "observation_period": "2024", "population": "HealthCare.gov QHP post-service medical and drug claims", "denominator": "in_network claims", "source_id": "KFFCLAIMS", "source_url": "https://www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/", "publication_date": "2026-03-24", "limitation": "Not all US insurers; not prior authorization requests." }, { "id": "kff24_out_of_network", "value": 37, "unit": "percent", "observation_period": "2024", "population": "HealthCare.gov QHP post-service medical and drug claims", "denominator": "out_of_network claims", "source_id": "KFFCLAIMS", "source_url": "https://www.kff.org/patient-consumer-protections/claims-denials-and-appeals-in-aca-marketplace-plans-in-2024/", "publication_date": "2026-03-24", "limitation": "Not all US insurers; not prior authorization requests." }, { "id": "kodiak_takebacks_2025", "value": 1.38, "unit": "percent", "observation_period": "First half 2025", "population": "Kodiak platform", "denominator": "accounts receivable", "source_id": "KODIAK26", "source_url": "https://www.businesswire.com/news/home/20260915724994/en/Falling-Rates-of-Insurance-Claim-Denials-Fail-to-Drive-Better-Financial-Performance-for-Hospitals-Health-Systems-and-Medical-Practices-According-to-a-Kodiak-Solutions-Analysis", "publication_date": "2026-09-15", "limitation": "Post-payment takebacks; not net revenue or share of claims." }, { "id": "kodiak_recoveries_2025", "value": 2.48, "unit": "percent", "observation_period": "First half 2025", "population": "Kodiak platform", "denominator": "accounts receivable", "source_id": "KODIAK26", "source_url": "https://www.businesswire.com/news/home/20260915724994/en/Falling-Rates-of-Insurance-Claim-Denials-Fail-to-Drive-Better-Financial-Performance-for-Hospitals-Health-Systems-and-Medical-Practices-According-to-a-Kodiak-Solutions-Analysis", "publication_date": "2026-09-15", "limitation": "Recoveries after payment; not an appeal success rate." }, { "id": "kodiak_takebacks_2026", "value": 1.57, "unit": "percent", "observation_period": "First half 2026", "population": "Kodiak platform", "denominator": "accounts receivable", "source_id": "KODIAK26", "source_url": "https://www.businesswire.com/news/home/20260915724994/en/Falling-Rates-of-Insurance-Claim-Denials-Fail-to-Drive-Better-Financial-Performance-for-Hospitals-Health-Systems-and-Medical-Practices-According-to-a-Kodiak-Solutions-Analysis", "publication_date": "2026-09-15", "limitation": "Post-payment takebacks; not net revenue or share of claims." }, { "id": "kodiak_recoveries_2026", "value": 2.21, "unit": "percent", "observation_period": "First half 2026", "population": "Kodiak platform", "denominator": "accounts receivable", "source_id": "KODIAK26", "source_url": "https://www.businesswire.com/news/home/20260915724994/en/Falling-Rates-of-Insurance-Claim-Denials-Fail-to-Drive-Better-Financial-Performance-for-Hospitals-Health-Systems-and-Medical-Practices-According-to-a-Kodiak-Solutions-Analysis", "publication_date": "2026-09-15", "limitation": "Recoveries after payment; not an appeal success rate." }, { "id": "kodiak25_combined_losses", "value": 48, "unit": "USD billion lower bound", "observation_period": "2025", "population": "Kodiak hospital platform", "denominator": "not applicable", "source_id": "KODIAK25", "source_url": "https://www.businesswire.com/news/home/20260331038554/en/Healthcare-Provider-Organizations-Saw-Net-Revenue-Losses-From-Final-Denials-and-Bad-Debt-Grow-by-25-in-2025-According-to-Kodiak-Solutions-Proprietary-Data", "publication_date": "2026-03-31", "limitation": "Reported as MORE THAN 48 billion; combines final denials and uncollected patient amounts, not denial-only losses." }, { "id": "experian26_missing_data", "value": 63, "unit": "percent", "observation_period": "January to February 2026", "population": "200 surveyed healthcare leaders", "denominator": "respondents", "source_id": "EXPERIAN26", "source_url": "https://www.experian.com/content/dam/marketing/na/healthcare/articles/eh_claim_denial_infographic_final.pdf", "publication_date": "2026", "limitation": "Cause selections overlap; respondent percentages are not claim-volume rates." }, { "id": "experian26_inaccurate_data", "value": 62, "unit": "percent", "observation_period": "January to February 2026", "population": "200 surveyed healthcare leaders", "denominator": "respondents", "source_id": "EXPERIAN26", "source_url": "https://www.experian.com/content/dam/marketing/na/healthcare/articles/eh_claim_denial_infographic_final.pdf", "publication_date": "2026", "limitation": "Cause selections overlap; respondent percentages are not claim-volume rates." }, { "id": "experian26_authorization_issues", "value": 59, "unit": "percent", "observation_period": "January to February 2026", "population": "200 surveyed healthcare leaders", "denominator": "respondents", "source_id": "EXPERIAN26", "source_url": "https://www.experian.com/content/dam/marketing/na/healthcare/articles/eh_claim_denial_infographic_final.pdf", "publication_date": "2026", "limitation": "Cause selections overlap; respondent percentages are not claim-volume rates." }, { "id": "experian26_rate_increased", "value": 24, "unit": "percent", "observation_period": "January to February 2026", "population": "200 surveyed healthcare leaders", "denominator": "respondents", "source_id": "EXPERIAN26", "source_url": "https://www.experian.com/content/dam/marketing/na/healthcare/articles/eh_claim_denial_infographic_final.pdf", "publication_date": "2026", "limitation": "Cause selections overlap; respondent percentages are not claim-volume rates." }, { "id": "experian26_rate_10_or_less", "value": 76, "unit": "percent", "observation_period": "January to February 2026", "population": "200 surveyed healthcare leaders", "denominator": "respondents", "source_id": "EXPERIAN26", "source_url": "https://www.experian.com/content/dam/marketing/na/healthcare/articles/eh_claim_denial_infographic_final.pdf", "publication_date": "2026", "limitation": "Cause selections overlap; respondent percentages are not claim-volume rates." }, { "id": "experian25_over10", "value": 41, "unit": "percent", "observation_period": "June to July 2025", "population": "250 surveyed healthcare professionals", "denominator": "respondents", "source_id": "EXPERIAN25", "source_url": "https://www.experianplc.com/newsroom/press-releases/2025/experian-health-s-3rd-annual-state-of-claims-survey-finds-denial", "publication_date": "2025-09-22", "limitation": "Publisher blog says claims denied at least 10% of the time. Not a matched panel with 2026 survey." }, { "id": "premier23_rework", "value": 57.23, "unit": "USD per contested denied claim", "observation_period": "2023 claims", "population": "280 surveyed hospitals in 23 states", "denominator": "contested denied claims", "source_id": "PREMIER", "source_url": "https://premierinc.com/newsroom/blog/claims-adjudication-costs-providers-257-billion-18-billion-is-potentially-unnecessary-expense", "publication_date": "2025-02-24", "limitation": "Voluntary hospital survey; not a current physician-practice price." }, { "id": "premier22_rework", "value": 43.84, "unit": "USD per contested denied claim", "observation_period": "2022 claims", "population": "Prior Premier survey comparison", "denominator": "contested denied claims", "source_id": "PREMIER", "source_url": "https://premierinc.com/newsroom/blog/claims-adjudication-costs-providers-257-billion-18-billion-is-potentially-unnecessary-expense", "publication_date": "2025-02-24", "limitation": "Historical comparison as reported by publisher." }, { "id": "premier23_national", "value": 25.7, "unit": "USD billion estimated", "observation_period": "2023 claims", "population": "US extrapolation from survey", "denominator": "not applicable", "source_id": "PREMIER", "source_url": "https://premierinc.com/newsroom/blog/claims-adjudication-costs-providers-257-billion-18-billion-is-potentially-unnecessary-expense", "publication_date": "2025-02-24", "limitation": "Modeled national cost, not an observed spending census." }, { "id": "actigy_start_clean_claim", "value": 84.1, "unit": "percent", "observation_period": "Engagement period not specified", "population": "Anonymized combined telehealth RCM engagement", "denominator": "clean claims as company defined", "source_id": "ACTCASE", "source_url": "https://actigy.com/case-studies/telehealth-rcm-clean-claims/", "publication_date": "2026-10-04 update", "limitation": "Company-reported, unaudited; not isolated denial-support effect." }, { "id": "actigy_end_clean_claim", "value": 97.8, "unit": "percent", "observation_period": "Engagement period not specified", "population": "Anonymized combined telehealth RCM engagement", "denominator": "clean claims as company defined", "source_id": "ACTCASE", "source_url": "https://actigy.com/case-studies/telehealth-rcm-clean-claims/", "publication_date": "2026-10-04 update", "limitation": "Company-reported, unaudited; not isolated denial-support effect." } ] }