Expert Insight

3 minute read

Why clinical criteria gaps are driving up insurance denials

Payers are denying more claims based on clinical criteria, not paperwork errors. Here’s what leaders need to know to get ahead of today’s surge in denials.

Denials from insurance payers have increased over the past several years, intensifying pressure on hospital revenue cycles. National denial rates have climbed from just over 10% in 2020 to nearly 12% in 2026, and more than 40% of providers now report denial rates above that threshold.1,2 As a result, industry estimates suggest that billions in hospital claims are initially denied each year.1 This places denials among the most significant sources of revenue disruption in healthcare.


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AFTER YOU READ THIS
  • You'll understand why clinical criteria gaps are driving higher payer denials.
  • You'll learn which diagnoses are most vulnerable to documentation‑driven denials.
  • You'll understand how leaders can prevent clinical denials before submission.

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