As someone who has spent a career immersed in healthcare data and finance, I’ve had a front-row seat to the often-frustrating dance between providers and payers. In 2023 alone, approximately 425 million health insurance claims were submitted to HealthCare.gov insurers. Of those, one in five—20%—were denied. In our review of millions of claims across all payers and plans, true denial rates fall closer to 10%-13%. While not all blame can be placed squarely on payers, these defect rates aren’t just noise in the system. It’s a signal of a structural challenge that’s leaving providers constantly reacting to denials rather than preventing them.
Too often, I see healthcare organizations bogged down in denial management, fighting to overturn decisions after the fact. It’s like treating symptoms without ever addressing the root cause: a lack of transparency and real accountability in payer behavior.
For years, this relationship has operated as a zero-sum game. Providers push for better rates; payers respond with more scrutiny and administrative friction. On the payer side, there’s a prevailing narrative that rising claims costs are driven by overcoding and abuse—justifying increasingly restrictive policies. But that narrative often masks a deeper problem: contractual non-compliance, inconsistent application of policies, and a growing reliance on opaque third-party vendors.
It’s time for a reset.
What if providers stopped playing defense and started using the data they already have to take control? The information exists—but too often, it’s locked in hundreds of spreadsheets (or maybe a dashboard if you’re lucky) that lack the specificity needed to drive action. A denial trend might show up, but the "why" remains elusive. This isn’t a technology issue—it’s a strategic knowledge gap, and data is the key to closing it.
The first step in changing the dynamic is deceptively simple: hold payers accountable to the terms they've already agreed to. This isn’t about being combative—it’s about using data to expose where payers deviate from agreed-upon medical policies, billing rules, and documentation standards.
This shift allows providers to do more than appeal after the fact. It lets them surface trends before they escalate—whether in quarterly check-ins or at the negotiating table.
One of the most revealing insights that we have seen in the data? The most problematic payers aren’t always the biggest. Regional or secondary plans—those that often fly under the radar—often have more egregious deviations from contract. These payers rarely get the same level of scrutiny, simply because most provider teams are stretched too thin to analyze every agreement with equal depth.
Imagine the impact if we applied the same level of scrutiny to every payer and contract—not just the thousand-pound gorillas. Denials and friction aren’t limited to the biggest names. By broadening the lens, providers can identify patterns, pinpoint inefficiencies, and recover revenue that’s been quietly leaking across the board. This is where technology can make the difference—bringing visibility, consistency, and leverage to every negotiation and reimbursement conversation.
This isn’t a one-sided issue. Many denials stem from provider-side coding and billing errors. Vague diagnoses, unspecified codes, outdated documentation practices—they all create openings for denials. The shift from ICD-9 to ICD-10 introduced immense specificity and complexity, and many organizations haven’t fully adopted that precision in practice.
Recognizing these internal gaps is not an admission of failure—it’s a strategic advantage. Fixing them strengthens a provider’s position, improves clean claim rates, and reduces the surface area for payer denials.
Complicating matters further is the rise of payment integrity vendors—third parties hired by payers to identify “savings opportunities.” These vendors are incentivized not to pay claims. And because they often operate in the gray space between stated policy and interpretation, they create a moving target that’s nearly impossible to hit without a data-driven defense.
Providers can’t afford to fight these battles blindly. They need clear visibility into how policies are being applied, where inconsistencies emerge, and what tactics are trending across the industry.
This is where data becomes power—not just for reporting, but for reshaping the relationship itself. A truly strategic data approach enables providers to:
Healthcare is too complex—and too important—to keep operating on misaligned incentives and murky accountability. Data offers a path forward. Not just for individual claims battles, but for transforming the entire payer–provider dynamic into one grounded in transparency, fairness, and shared responsibility.
By shifting from reactive denial management to proactive data strategy, providers can stop playing defense and start shaping the rules of the game.
