A recap of MDaudit’s HFMA 2026 Thought Leader Roundtable and the insights shared by revenue cycle leaders from across the country
HFMA’s theme for 2026, Dare to Solve, couldn’t have landed at a more fitting moment for revenue cycle and compliance leaders. Because the problems on the table right now aren’t incremental. They aren’t solvable with more staff, better spreadsheets, or incremental process improvement. They require organizations to look squarely at what’s broken and commit to solving it: boldly, structurally, and with the right tools.
At HFMA’s Annual Conference last week, MDaudit moderated a thought leader roundtable on one of the most urgent challenges in healthcare finance: the AI arms race between payers and providers. The room was diverse, with senior leaders from large academic medical centers, regional health systems, rural hospital collaboratives, and state hospital networks all navigating versions of the same storm.
What follows are the themes that surfaced. For each one, we’ve tried to name not just the problem, but the dare: the specific challenge HFMA’s theme is asking our industry to accept.
The Problem: Payers Are Playing Offense. Most Providers Are Still Catching Up.
Payers are deploying artificial intelligence at scale to manage and deny claims, and it is working in their favor. Authorization denials, once the dominant concern, are actually declining at some organizations. But they are being replaced by something harder to fight: complex, line-item underpayments (often in the form of downcoded claims) with vague or absent denial reasons. Payers are auto-downcoding ED claims, disputing DRG assignments, and sliding underpayments in volumes too high for most revenue cycle teams to manually review and contest.
The structural asymmetry is real. Payers have one core function: manage claims payment. Providers are running hospitals, caring for patients, managing staff, navigating regulation, and also trying to get paid accurately for all of it. The message from the room was clear: fighting AI-powered denials with manual processes is no longer viable. The only way to keep pace is to match the payer’s sophistication with your own.
The Dare: Stop treating denials as a back-end cleanup problem. Build a proactive, AI-powered offense before claims leave the building.
MDaudit’s Risk Analytics and eValuator are built for exactly this shift, catching high-dollar denial risk before claims leave the building, surfacing the payer patterns driving the most financial exposure, and ensuring coding accuracy at the point of care before a single claim is submitted.
The Problem: Downcoding Is a Compliance Trap, Not Just a Revenue Issue.
One of the most striking conversations at the roundtable centered on downcoding, specifically the growing conflict between provider clinical criteria and payer payment criteria. Multiple participants described scenarios where payers refuse to pay claims unless providers change their coded diagnoses. A common flashpoint: conditions like sepsis, where clinical documentation, physician attestation, and established internal protocols all support the original code. The payer’s position is blunt: change the code or don’t get paid.
The compliance dimension is significant and underappreciated. Providers cannot compliantly alter a claim to match payer criteria that contradicts their own clinical documentation. Yet holding the claim means sitting on unpaid revenue for months or years while escalating through appeals, legal, and contracting channels.
The leaders in the room were unified on this point: no amount of payer pressure justifies changing a compliantly coded claim. For many organizations, this has moved from a revenue cycle conversation into a legal and contracting one.
The organizations navigating this most effectively have built multidisciplinary governance structures, with coding, CDI, physician advisory, contracting, and legal all at the same table, armed with aggregate data packages that reframe individual disputes as systematic payer tactics. Data is their weapon. Volume is their leverage.
The Dare: Build the infrastructure to hold your ground to include defensible documentation, trend data, and cross-functional alignment that turns one-off disputes into a coordinated payer strategy.
MDaudit’s Hospital Billing Workflow, Professional Audit Workflow, and Coder Audit Workflow give teams the risk-prioritized audit infrastructure and documentation trail to do exactly that, ensuring defensible coding decisions across every care setting and claim type.
The Problem: Payer Audits Are Overwhelming the Organizations Built to Handle Them.
Audit volume has doubled or tripled in recent years, but the number of cases per audit has quadrupled. For organizations with multiple facilities, particularly those with rural or critical access hospitals, the logistics of receiving, routing, and responding to audit correspondence have become a crisis in their own right.
Audits arrive by fax, email, spreadsheet, and physical mail. At some facilities, faxes still land in shared clinical spaces rather than revenue cycle teams. Letters sit undiscovered. Deadlines pass. Automatic recoupments arrive up to a year or more later in some cases. And because the payer audit ecosystem involves multiple parties and processes, having a centralized, technology-enabled approach to intake and response has never been more important.
What was clear from the room is that fragmentation is the enemy. Organizations are losing revenue not because they lost the appeal, but because they never knew the audit arrived. Organizations getting ahead of this are centralizing intake, leveraging eMDR and esMD, and using AI-powered tools to ingest and parse correspondence at scale.
The Dare: Centralize your audit infrastructure before the next wave hits. The payers have already systematized this. Providers needs to match it.
MDaudit’s Payer Audit Workflow processes payer letters from any format in ~40 seconds with 95%+ accuracy. Across MDaudit’s community, customers have processed 20,000+ payer letters and retained more than $200M in at-risk revenue.
The Problem: Autonomous Coding Has Everyone’s Attention — But Governance Is the Key To Success
Nearly every organization at the roundtable is evaluating autonomous coding. None are fully deployed. The consistent theme: the technology has potential, but the accountability infrastructure isn’t ready. The concern isn’t accuracy per se, it’s ownership. Who is responsible when an AI-coded claim is wrong? What does the QA model look like? Who has the expertise to catch what the model misses?
The leaders closest to getting this right described a “human in the loop” philosophy, using autonomous coding to elevate their teams rather than replace them. Experienced coders and compliance professionals become quality reviewers of AI output rather than first-line processors. The goal isn’t removing human expertise from the coding process. It’s applying that expertise at a higher level, to the patterns, outliers, and edge cases that require judgment.
Across the room, there was broad agreement that governance needs to scale beyond individual departments. Forward-looking health systems are moving toward unified enterprise AI governance with domain subcommittees, treating AI accountability as a C-suite function rather than a departmental one.
The Dare: Don’t wait for a perfect governance framework before acting. Build it while you move and with the right human oversight baked in from the start.
MDaudit’s eValuator™ is built for this model. It applies AI-enabled rules to 100% of encounters pre-bill, triggering expert review where it matters most. Average ROI: 12x. Average break-even: 45 days. Average ROI: 12x. Average break-even: 45 days.
The Problem: Silos Are Still Costing Organizations the Fight.
The roundtable’s final conversation surfaced the widest range of maturity. Some organizations still run professional billing and hospital billing as parallel worlds. Others have built fully integrated, end-to-end revenue cycle functions with CDI, coding, denials, utilization management, and appeals under unified leadership.
The difference showed up clearly in how each organization described its ability to fight payer tactics. The leaders who felt most equipped, on downcoding disputes, audit volume, and contract negotiations, were those whose revenue cycle, compliance, legal, and contracting teams were already operating as one. Not because of any single technology, but because they had done the organizational work to align around shared data and shared goals.
The most advanced organizations in the room described a model where the silos aren’t just being reduced, they are being actively dismantled, with clinical and finance functions brought together under a shared understanding that documentation accuracy and revenue integrity are two sides of the same coin.
The Dare: Treat silo-breaking as a strategic initiative, not a cultural aspiration. The payers are running integrated operations. Providers that match that integration are the ones winning.
MDaudit’s revenue integrity platform is built around this principle, unifying risk mitigation and revenue optimization in a single environment so that compliance findings, denial trends, coding integrity data, and audit responses inform each other.
Accepting the Challenge
HFMA’s call to Dare to Solve is not abstract. The leaders in our roundtable were already living it, holding claims on principle, building governance structures from scratch, centralizing audit intake across dozens of rural facilities, and demanding that legal, coding, clinical, and finance sit at the same table.
They weren’t waiting for perfect conditions. They were solving with the urgency the moment demands.
The data backs up what we heard in the room. MDaudit customers have increased risk-based audits by 25% and pre-bill audits by 30% since 2025. They’ve retained $280M+ annually through payer audit defense and achieved double-digit ROI multiples across core platform modules. The organizations driving those outcomes share one thing: they stopped accepting the problem and started solving it.
If you’re ready to take HFMA’s challenge seriously, let’s talk about what solving looks like for your organization.
