From relentless claim denials and payer pressures to policy debates around prior authorization and the 340B program, this mid-year briefing unpacks the six essential stories every revenue cycle leader needs to know.
It's been a busy first half-year for revenue cycle leaders. From the continued rise in claim denial rates to increased scrutiny over the 340B Drug Pricing Program to uncertainty surrounding funding for government-backed health plans, there has been a lot of news to follow.
At the six-month mark, we take a look at the most read stories shaping the revenue cycle landscape.
No Denying There's a Claim Denial Problem
Around 85% of revenue cycle leaders surveyed for the 2024 Experian Health State of Claim say reducing denials is a top priority for their organizations, and about three-quarters say they are seeing more denials.
However, it's not just quantity that's keeping revenue cycle leaders up at night.
“We are seeing more – not only in volume, but in ambiguity and variety and complexity,” Beth Carlson, VP Revenue Cycle at WVU Health, told HealthLeaders earlier this year.
Let's Get Digital: How 2 RCM Leaders Are Tapping Tech to Improve Patient Access
As patients shoulder growing financial responsibility for their healthcare costs, revenue cycle leaders are turning to technology to improve access. Ballad Health, for instance, has partnered with payers on data exchange to streamline patient registration and offer more digital tools for patients to manage scheduling and payments.
"We're really, really pushing our organization forward into the digital," Shana Tate, Ballad Health's chief revenue officer, told HealthLeaders.
Executive Order Puts 340B Drug Pricing Back in the Spotlight
The Trump administration reignited debate over the 340B Drug Pricing Program when it issued an Executive Order on drug pricing for insulin and injectable epinephrine while also instructing HHS to consider reimbursement adjustments for discounted drugs.
Hospitals participating in the program say the 340B discounts are essential to their organizations' financial health. However, critics say many hospitals fail to use the funds for the marginalized populations that the program was intended to help.
Congress Considers Legislation to Restrict Prior Authorization
With provider frustration over prior authorization (PA) reaching a boiling point, policymakers have been exploring legislation to limit burdensome requirements from payers.
Earlier this year, Rep. Mark Green, MD (R-TN) introduced the Reducing Medically Unnecessary Delays in Care Act of 2025. The law would require physician review of PA decisions for payers participating in federal health programs and require increased transparency on claim denial rates and PA criteria.
“No one should lose out on medical care because an AI algorithm is challenging what a doctor has already deemed a necessity,” Kim Shrier, MD (D-Washington), a cosponsor, said in a statement.
Payers' Rising Costs Spell Trouble for Rev Cycle Leaders
Payers were hit with higher-than-expected medical costs and lower-than-expected premium revenue to close out 2024. In January, UnitedHealthcare revealed in an earnings report that high demand for services among Medicare and Medicaid beneficiaries was a main driver behind its poor financial performance. Cigna, too, failed to meet earnings projections in the final quarter of 2024.
Financial woes at some of the largest payers should put revenue cycle leaders on alert. Payers will likely look to premium increases and provider reimbursement to boost their bottom lines.
Payer-Provider Software: 5 Strategies for Smooth Sailing
Revenue cycle teams are increasingly reliant on a wide range of technology, but finding solutions that actually reduce friction is easier said than done, according to Debbie Schardt, vice president of revenue cycle and utilization management at MultiCare Health System.
To ensure that technology solutions are effective, health systems need a clear vision and strategy to properly vet vendors, Schardt says.
Luke Gale is the revenue cycle editor for HealthLeaders.
KEY TAKEAWAYS
The unrelenting rise in the volume and complexity of claim denials continues to plague revenue cycle operations.
Increased scrutiny on the 340B Drug Pricing Program and prior authorization practices could signal impending policy changes.
As technology becomes more central to the revenue cycle, successful software implementation on a clear strategies for vendor selection, staff buy-in, and performance measurement.