State of Healthcare
Denials 2026
Use this guide to build a defensible denial trend report from your own claim, remittance, payer, and appeal data. DenialPro does not present proprietary industry percentages on this page unless the underlying dataset and methodology can be substantiated.
What to Measure
Build the report around real root causes
A useful denial report should explain what happened, where the breakdown occurred, what action followed, and whether revenue was recovered. Start with your own payer responses instead of applying a generic national percentage to your organization.
Eligibility & Coverage
Track coverage termination, inactive coverage, coordination of benefits, Medicare Advantage enrollment, and payer-order issues separately so front-end causes are visible.
Prior Authorization
Separate missing authorization, expired authorization, service mismatch, unit or visit exhaustion, and payer-specific authorization requirements instead of grouping every issue together.
Medical Necessity
Review the denied service, payer policy, LCD or NCD when applicable, documentation, diagnosis support, and appeal rights before assigning a root cause.
Timely Filing
Track true late filing separately from payer receipt problems, rejected claims, incorrect payer submission, and situations where proof of timely filing exists.
CARC & RARC Patterns
Use the full CARC, RARC, group code, claim status, and payer response together. A single code should not be treated as the complete denial explanation when additional payer information is available.
Appeals & Recovery
Measure appeal volume, overturns, partial payments, upheld denials, turnaround time, and dollars recovered using your own organization data rather than generic benchmark assumptions.
Methodology
A defensible reporting method
Define exactly what counts as a denial, rejection, adjustment, appeal, and recovery in your reporting.
Use claim-level or line-level data consistently so rates are not mixed across different denominators.
Group root causes by workflow stage such as registration, eligibility, authorization, coding, documentation, claim submission, payer processing, and follow-up.
Review payer, service line, location, provider, and denial-code trends separately before combining them into an enterprise summary.
Validate unusual spikes against remittance data, claim status, and workflow changes before labeling them as a trend.
Document the reporting period, data sources, exclusions, and calculation method so future comparisons use the same rules.
About benchmark data
Industry benchmark figures can be useful when they come from a named, reviewable source with a clear reporting period and methodology. DenialPro should not label internally generated sample numbers as industry data or imply that it analyzed external organization remittance files unless that research actually occurred.
Continue your denial analysis
Use DenialPro's reference and practice tools to investigate individual denial patterns, then apply the same logic to your organization's own data.