The healthcare revenue cycle is at a crossroads. As payer policies evolve at an unprecedented pace, providers struggle to keep up—leading to denials that erode financial performance and stretch already burdened teams. Denial rates above 10% are reported by 38% of providers, and nearly half of those denials are due to missing or inaccurate data. The financial and operational impact is staggering: healthcare systems spend $20 billion annually managing denials, with physicians dedicating over 14 hours each week to prior authorizations.
But the industry is shifting. With growing public scrutiny of patient denials and the rise of real-time adjudication initiatives by major players like Optum and Elevance has created a meaningful opportunity to use real-time clinical data to bridge the gap between payer expectations and provider workflows.
The Challenge of Mid-Cycle Denials
The mid-revenue cycle is a hotspot for denials. Historically, payers concentrated their efforts on front-end denials, such as authorization issues, but recent public scrutiny over patient-facing denials is forcing a shift. As a result, mid-cycle denials—those tied to clinical documentation and coding—are emerging as a new focus area.
This trend isn’t coincidental. Payers are leveraging the increasing complexity of clinical documentation requirements to identify opportunities for denial or reimbursement reduction. Policies evolve rapidly, creating a moving target for providers who often lack the tools to adapt. The result: denials tied to insufficient clinical documentation or misaligned coding that providers may not catch until claims are rejected in high volumes.
Sepsis is a clear example of this challenge. Definitions and criteria vary across payers, and the clinical elements required to justify a diagnosis—such as lab values, organ dysfunction indicators, and treatment plans—can change with little notice. Without tools to proactively address these nuances, providers often don’t discover documentation gaps until claims are denied, leading to revenue loss and rework.
Mid-cycle denials create financial strain and disrupt clinical workflows. Addressing them requires tools that surface payer-specific requirements at the point of documentation or coding, enabling providers to adjust in real time. By proactively aligning documentation with payer policies, providers can reduce denials, streamline processes, and minimize the operational burden on their teams.
Transforming Healthcare Reimbursement Through Clinical Data
Sift, in partnership with clinical workflow platform providers, is driving a paradigm shift in claims adjudication by providing payers with comprehensive clinical data alongside traditional claim information. This integration enables real-time, data-driven decisions that align reimbursement with actual care delivery rather than just administrative codes.
Unlike players such as Optum or Elevance, which focus heavily on payer-driven workflows, Sift and our clinical workflow partners are building solutions that prioritize empowering providers by integrating directly into their CDI and coding processes. This provider-centric approach bridges the gap between payer expectations and provider workflows, allowing providers to proactively address documentation gaps before claims are submitted.
For example, when physicians document a patient's sepsis diagnosis, the clinical criteria they include directly impact payment. Real-time clinical data integration (along with ML models that predict denials) alerts providers if the documentation lacks elements that affect reimbursement, such as specific organ dysfunction indicators or lab values that support the diagnosis's severity.
This approach prevents problems before they happen, fundamentally changing how providers interact with payers.
Market Momentum
Major payers and technology leaders are actively investing in solutions enabling direct, real-time adjudication – Epic has advanced plans to enable direct claims submission, bypassing clearinghouses entirely. This aligns with broader industry efforts to reduce administrative complexity and accelerate reimbursement cycles.
- Real-Time Adjudication: Optum, Elevance, and others are investing heavily in automated adjudication, aiming to settle claims in seconds.
- Value-Based Care: Contracts like CalPERS’ value-based arrangement for 400,000 members demand real-time payment intelligence to manage risk and align clinical documentation with payment goals.
- Payer Policy Volatility: With 77% of providers citing increasing payer policy changes, static systems are no longer sufficient. Adaptive, real-time solutions are essential to keeping up.
These market signals indicate growing recognition that traditional claims processing no longer serves healthcare's evolving needs. The industry is moving decisively toward solutions that enable real-time clinical data sharing and automated adjudication.
Realizing Value Through Real-Time Payment Intelligence
Real-time clinical data integration creates measurable value for both payers and providers. For health systems, this shift reduces the $20 billion spent annually on denials management while enabling proactive interventions before claims submission.
For payers, access to comprehensive clinical data alongside claims information enables more accurate, efficient reimbursement decisions. This reduces both overpayments and underpayments while strengthening provider relationships through transparency. The results will be significant improvements in clean claims rates and reduced administrative overhead.
The future of reimbursement isn’t about fixing denials after the fact. It’s about preventing them entirely, aligning care delivery with payment, and ensuring that healthcare systems can focus on what matters most: their patients.