Healthcare organizations are navigating one of the most financially and regulatorily complex environments in recent memory. In response, our webinar, Beyond the Audit: How Billing Compliance is Redefining Revenue Integrity, showed data from thousands of facilities, over 1.2 million providers, and more than $200 billion in denials analyzed annually.
Here’s what you need to know.
What Is Revenue Integrity — Really?
Revenue integrity isn’t about just one function. It’s a cross-functional discipline that spans revenue cycle, billing operations, coding, clinical documentation, and patient experience, with all these functions reading from the same data but asking different questions.
That’s why siloed approaches to revenue cycle management leave money on the table and create compliance exposure. Sustainable revenue integrity requires alignment across all these stakeholders, supported by shared data and accountability.
As part of this model, we unpacked six critical billing compliance insights from the 2025 MDaudit Benchmarking Report and outlined what revenue integrity leaders need to prioritize in 2026 and beyond.
6 Billing Compliance Insights from the 2025 Benchmarking Report
Insight #1–#3: Early-Stage Trends Shaping the Landscape
The benchmarking data, compiled across 45 states, 20 payer types, 4,500+ facilities, and $20B+ in annual charges audited, identified three macro-level forces shaping the revenue integrity environment today:
- Denials are rising across the board. Average denied amounts increased by double digits year-over-year — 14% in hospital outpatient settings and 12% in inpatient settings.
- Payer audits are intensifying. The total at-risk amount and audit cases per customer increased 30% for external payer audits, with the average per-claim amount up 18%.
- Technology is separating winners from laggards. Risk-based audits within MDaudit’s platform increased 25%, and pre-bill audits increased 30%, a clear signal that proactive, AI-enabled approaches are gaining ground.
Insight #4: Coding-Related Denials Jumped 26% (and That’s on Top of Last Year’s 126% Surge)
One of the most striking findings in the report: coding-related denials continued their dramatic rise in outpatient settings. The 26% increase in 2025 is incremental to the 126% increase reported the year prior.
The top drivers were errors in diagnosis coding, modifier usage, and insufficient medical record documentation. Hospital outpatient average denied amounts from coding issues rose from $368 to $453 (23%), while professional claims climbed from $115 to $148 (29%).
What’s behind the trend? A meaningful contributor is the rapid adoption of autonomous coding technologies — AI systems deployed to address the ongoing shortage of qualified coding professionals. When governance and human oversight aren’t built into these systems, coding errors can propagate at scale. A recent BCBS Association issue brief put it plainly: coding AI can propose additional billable diagnoses or higher-severity combinations that increase reimbursement even when the care delivered is unchanged. The result is both a compliance risk and a reimbursement risk.
Healthcare organizations that layer a closed-loop coding integrity function on top of their AI coding investments will be far better positioned to catch errors before they become denials — or worse, audit findings.
Free Resource: MDaudit has published a checklist of 7 Best Practices for Auditing Autonomous Coding Systems, covering governance, performance benchmarking, drift monitoring, tiered audit approaches, and more.
Insight #5: RFI and Medical Necessity Denials Surged 70% Across All Settings
The data on request-for-information (RFI) and medical necessity denials is difficult to ignore. Average denied amounts in this category rose 60% in professional settings, 28% in hospital outpatient, and a staggering 123% in inpatient settings.
The payer types driving the sharpest increases are commercial insurance (up 176%) and Medicare Advantage plans (up 390%) in this denial category alone.
These numbers underscore the importance of documentation discipline and pre-bill review workflows. Clinical staff and coders need the tools and feedback loops to ensure that the documentation submitted supports the level of service being billed — before the claim goes out the door.
Insight #6: External Payer Audits Are Up 30%, with Commercial Payers Leading the Charge
The at-risk revenue picture from external payer audits is equally concerning. The average at-risk amount for a hospital setting was approximately $17,000 per audit; in professional settings, it was $1,172. Commercial payers accounted for 45% of total at-risk amounts, with Medicare and Medicaid at 28%.
In hospital settings, audit requests were primarily driven by coding errors, medical necessity challenges, and billing errors. In professional settings, coding and billing errors were the dominant drivers.
The webinar also highlighted specific CPT, HCPCS, and DRG codes currently under heightened payer scrutiny — from metabolic panels and propofol injections in hospital outpatient settings to septicemia and cardiac valve procedures in inpatient DRGs. Revenue teams should ensure these codes are receiving appropriate audit attention.
Finally, the session touched on the growing risk of auto-downcoding by Medicare Advantage (MA) Payers, a tactic where MA plans systematically pay at a lower level of care than billed. Accepting these payments without challenge may expose organizations to False Claims Act liability, according to recent analysis from RACmonitor.
2026 Predictions: What Revenue Integrity Leaders Should Prepare For
The webinar covered four forward-looking predictions for 2026 and beyond:
- Denials will become more complex — and more preventable. Health systems deploying pre-bill revenue integrity solutions with predictive analytics will gain a measurable edge.
- Payer audit escalation will require continuous monitoring. Organizations with centralized audit tracking and automated risk monitoring will reduce response times and protect more revenue.
- Technology adoption will shift from optional to survival. Providers leveraging AI-powered revenue integrity platforms will see exponential gains in operational efficiency and denial overturn rates compared to those that don’t.
- Outpatient coding accuracy will define financial performance. The organizations that win the reimbursement race will be those that treat coding integrity as a continuous, data-driven function, not a periodic audit exercise.
Beyond the Audit
Billing compliance teams are uniquely positioned to redefine revenue integrity in meaningful ways. Revealed by 2025 benchmarking data, the revenue integrity environment is accelerating, and stabilization is the most critical piece. This is where billing compliance shines.
Denials are indeed more frequent, payer audits are more aggressive, and the technologies meant to solve coding capacity challenges are introducing new compliance risks without proper governance.
But billing compliance and revenue integrity leaders who invest now in proactive, technology-enabled audit workflows and who break down the silos between revenue cycle functions are the ones who will sustain financial performance in 2026 and beyond.
Catch the replay: Beyond the Audits: How Billing Compliance is Redefining Revenue Integrity, or Request a Demo to learn more.
