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Aetna’s policy change, which may have been delayed to Jan. 1, still means more Medicare Advantage admissions will be paid for as observation rather than inpatient. The burden shifts to hospitals to catch the downgrade, document severity and appeal it. The criteria are vague and billing systems were never designed to surface payment downgrades that don’t appear as denials. That combination has real implications for revenue integrity and margin protection heading into 2026. Hospitals will need tighter documentation processes, better visibility into downgrades and much clearer payer-side intelligence. Healthcare Financial Management Association (HFMA) Dominic Foscato https://lnkd.in/gyKe6efJ

Most health systems are losing $5M–$10M in revenue each year, that is fully preventable. Not because teams aren’t working hard. Not *just* because payers are getting more aggressive (they are). But because the same 3 denial classes keep slipping through the cracks: 1) Authorizations → $2–3M per $1B in revenue 2) Medical Necessity (CARC 252) → frequently recoverable with the right documentation 3) Registration & Eligibility → “small errors” that quietly turn into $1.5M per $1B in losses And here’s the kicker: Most organizations already have the staff to prevent these losses. What they don’t have is clarity about root causes and prioritization. So we built a CFO Briefing that: -Shows exactly where the first $5–10M sits -Quantifies the financial impact -Highlights which denials are actually worth pursuing -Outlines workflow fixes that protect future margin No fluff. No 200-page playbook. Just straight financial impact. If you want the CFO Briefing: ➡️ Comment “BRIEF” or ➡️ DM us, and we'll send it directly. This is a quick path to reclaiming margin in 2025. No new headcount required.

When you look at the most-read #revenuecycle articles on HealthLeaders Media this quarter, a pattern emerges. Cigna, Aetna, CMS, different players, same theme. Payers are rewriting the rules faster than providers can adjust. And even the “outlier” topic on this list (#5, #AI for denial prevention) is really about the same issue. How to keep up when the game keeps changing. Denials, downcoding, prior auth are all symptoms of the same problem. Systems built for static rules in a world that’s constantly shifting. The data, workflows and oversight processes that used to be “good enough” no longer are. It’s telling that four of the top five articles are, at their core, about denials management. The problem is growing, and it’s clear that current tools aren’t closing the gap. AI and proactive analytics aren’t a silver bullet, but they’re the only real way forward. Not to replace human expertise, but to give it a fighting chance against the speed of payer change. https://bit.ly/4osIHGl

Every month, health systems face millions in denied claims, but most denials reporting stops at totals. Sift's Denials Insights goes deeper, showing: • System-specific denial benchmarks across facilities and CARCs • Payer and denial class trends that drive friction • Overturn and prevention scoring to guide appeals and fixes • Root cause identification and actionable recommendations for denial prevention Download the full report today.

Health systems lose millions to preventable denials. Authorizations: $2–3M per $1B. Medical Necessity (252): most frequently overturned. Registration & Eligibility: $1.5M per $1B. Get the CFO Briefing: The first $5–10M in recoverable revenue.

Most hospital revenue cycle teams already have *some* AI tools. Copilot likely came bundled with your Microsoft 365 agreement, and for many teams, it's been sitting there, mostly idle. We wrote a prompt guide to get your team started. 20 prompts you can run in Copilot (Excel, Word, PPT and chat) against the denial exports and AR files your team already pulls: denial concentration by payer, appeal letters, CFO briefings, payer negotiation prep. The guide also helps identify where general AI tools stop reading your denial data, and where deeper Payments Intelligence (predictions, scoring, prevention, actionability) begins. As payers lean harder on AI to deny, downgrade, and delay, this Payments Intelligence layer is turning from nice-to-have into necessary. But, start with the prompt guide first.