Healthcare declare denial statistics: State of Claims Report 2025

Key takeaways:

• As claims denial charges proceed to climb, stress is mounting on healthcare organizations to seek out new methods to scale back denials.
• Leveraging synthetic intelligence (AI) and automation-based instruments, like Experian Well being’s AI Advantage™ and Patient Access Curator™ options, is confirmed to decrease denial charges.
• More than half of survey respondents say they’d exchange present claims administration platforms if offered with compelling ROI to make the change.

Claim denials are a well-documented problem for healthcare organizations. Denied claims take for much longer to pay out than first-time claims, in the event that they receives a commission in any respect. Each means further hours of rework and follow-up, pulling in additional assets as workers assessment payer insurance policies and work out what went flawed. It’s time-consuming and dear. Past {dollars} and paperwork, denials have an effect on affected person care as uncertainty about funds results in delays in therapy or surprising out-of-pocket prices.

However how do healthcare leaders really feel concerning the state of claims administration right this moment? How are they tackling the executive burden? Is there any gentle on the finish of the denials tunnel? Experian Well being surveyed 250 healthcare revenue cycle leaders to seek out out.

The 2025 State of Claims report breaks down the survey findings, together with insights into how automation and AI expertise are getting used (or not!) to optimize the claims course of for denial prevention and enhance income.

What’s the present denial fee for healthcare claims?

Well being claims are nonetheless caught in a cycle of denials, delays and knowledge errors. 41% of survey respondents mentioned that at the very least one in ten claims is denied. That’s quite a lot of rework and misplaced income that suppliers had been relying on.

In 2009, claims processing accounted for round $210 billion in “wasted” healthcare {dollars} within the US. A decade later, the invoice had climbed to $265 billion. Trade reviews – together with Experian Well being’s State of Claims collection – repeatedly noticed an increase in denial charges.

Right this moment, 54% of providers agree that declare denials are rising. And with this enhance, suppliers continually fear about who pays – and when.

What are the most typical causes for healthcare declare denials?

Based on the State of Claim survey respondents, the highest three causes for denials are lacking or inaccurate knowledge, authorizations and inaccurate or incomplete affected person data. Briefly? The issue is dangerous knowledge.

26% say that 10% of denials end result from inaccurate or incomplete knowledge collected at affected person consumption. Given how a lot info needs to be processed and arranged to fill out a single declare, this isn’t shocking. From affected person info to altering payer guidelines, the sheer quantity of information factors to be collected and collated creates too many alternatives for errors and omissions.

Different challenges, similar to coding errors, uncovered providers, eligibility checks, and staff shortages nonetheless play a job, however it’s clear that fixing the info drawback may make a significant dent within the denials drawback.

Might automation enhance declare denial statistics?

To assist break the denial spiral, extra healthcare suppliers are turning to claims management software. Leveraging expertise helps organizations resolve or stop the snags that intrude with claims processing and billing workflows – increase declare success charges. That mentioned, around half of providers nonetheless assessment claims manually.

But, regardless of the confirmed advantages of built-in workflows and automation, the drive to implement new expertise appears to have misplaced momentum.

In 2025, 41% of survey respondents say they upgraded or changed their claims administration expertise within the final yr. Nonetheless, 56% say that their present claims expertise is adequate to deal with income cycle calls for – far beneath the 77% in 2022.

Whereas some duties nonetheless genuinely require a human contact, workers time is usually wasted on repetitive, process-driven actions that will be higher dealt with via automation.

Listed below are just a few methods claims automation will help improve claim denial statistics:

• Join the whole claims course of end-to-end: Utilizing an automatic, scalable claims administration system – like ClaimSource® – helps suppliers handle the whole claims cycle in a single software. From importing claims information for sooner processing to mechanically formatting and submitting claims to payers, it simplifies the claims modifying and submission course of to spice up productiveness.
• Submit extra correct claims: 68% of survey respondents say submitting clear claims is more difficult than a yr in the past. There’s a powerful case, then, for utilizing an automatic declare scrubbing instrument to scale back errors. Claim Scrubber opinions pre-billed claims line by line so errors are caught and corrected earlier than being submitted to the payer, leading to fewer undercharges and denials and higher use of workers time.
• Enhance money movement: Automating declare standing monitoring is one option to speed up claims processing and time to cost. Enhanced Claim Status eliminates handbook follow-up so workers can course of pended, returned-to-provider, denied, or zero-pay transactions as shortly as potential.
• Cut back denials: Denials Workflow Manager automates the denial course of to eradicate the necessity for handbook opinions. It helps workers determine denied claims that may be resubmitted and tracks the basis causes of denials to determine developments and enhance efficiency. It additionally integrates with ClaimSource, Enhanced Claim Status and Contract Manager, so workers can view declare and denial info on a single display.

Enhancing declare denial statistics with AI

Whereas automation hurries up the denials workflow by taking good care of knowledge entry, AI can study that knowledge and suggest subsequent steps.

Of the 14% of survey respondents who mentioned their group is at the moment utilizing AI, 69% say that AI options have boosted claims success charges, decreasing denials and/or rising the success of resubmissions.

Present ClaimSource customers can now degree up their total claims administration system with AI Advantage, which interprets historic claims knowledge and payer habits to foretell and stop denials. The video beneath offers a useful walk-through of how AI Advantage’s two choices, Predict Denials and Denial Triage, will help suppliers reply to the rising problem of denials.