Denials went down this year, and cash still slowed. In September, TechTarget reported on an analysis of claims from thousands of hospitals and about 375,000 physicians. The initial denial rate fell to 10.63% in the first half of 2026, down from 12.00% a year earlier. Over the same period, 60-day cash performance slipped from 100.28% to 96.74%, and takebacks rose to 1.57% of accounts receivable from 1.38%.
For a practice leader, that combination is the one worth sitting with. The metric most groups watch closely improved, and the money arrived more slowly anyway.
What that slip looks like in dollars
Percentages are easy to nod at, so here’s a simple illustration. The figures are hypothetical, chosen only to show scale.
Picture a specialty group that expects $2 million a month in net revenue. If that group saw the same 3.5-point slip in 60-day cash performance, roughly $70,000 of each month’s expected cash would land later than it used to, and some of it might not land at all. Over a year, that’s a sizable sum moving out of the window when the practice planned to use it, and that shows up fast in cash planning for the next quarter.
Takebacks are only one piece of that picture. When MGMA asked practice leaders in July why their days in A/R had risen, they described several pressures at once, including slower payment, initial denials, downcoding, requests for medical records, prepayment audits and long appeal timelines. Cash slows when several of those pile up together, and the useful work for a group is figuring out which ones are hitting its own claims.
Four different problems, each found in a different place
It helps to separate these issues, because they happen at different points in a claim’s life and each one calls for a different response.
Recoupments happen after payment. A payer pays a claim and later recovers some or all of that money, sometimes through a repayment request and often through an offset against a future payment on a different patient. Recovery of overpayments is contractually permitted, and some recoupments are correct. The difficulty is visibility. The person posting the remittance sees a smaller deposit, and unless somebody traces the offset back to the original claim, nobody knows which recoupments were valid and which deserve a dispute.
Downcoding happens during adjudication. Here the payer reviews the claim before paying it and pays at a lower level than billed. Aetna’s Claim and Code Review Program, for example, reviews level 4 and 5 E/M visits for select providers. The payment arrives already reduced, so the claim never shows up as a denial. Our next field note covers how these programs work.
Underpayment is a contract issue. A claim can carry the right code, pass review untouched and still be paid below the rate the group negotiated. That has nothing to do with coding. It happens when the allowed amount doesn’t match the fee schedule, and without a way to compare expected and actual payment, the gap can go unnoticed for months.
Records requests and prepayment reviews delay payment. They don’t necessarily reduce what’s paid. The claim sits while someone pulls the chart and sends the packet, and the balance ages the whole time.
Each of these needs its own line in reporting and its own owner, because the fix for a contract underpayment looks nothing like the fix for a downcoded visit.
What leaders say, and what the denial rate measures
In a January MGMA poll, 48% of medical group leaders named denials and appeals as their largest source of revenue leakage. MGMA’s benchmark first-submission denial rate for practices sits around 7% to 8%.
Those two figures measure different things. The benchmark describes how often claims are denied on first submission. The poll, by contrast, captures where leaders feel the financial strain. A modest denial rate can still carry a heavy workload, since every denial has to be researched and worked, and appeals take time to resolve. For most groups, the practical point is that the denial rate alone won’t show the full picture. Recoupments and underpayments post as payments or adjustments, so tracking them takes a separate look at the remittance.
Why small differences add up for specialty groups
Specialty groups carry a lot of revenue in the services payers review most closely, such as higher-level visits and procedures with bundling and global-period rules. That’s a reasonable place for payers to focus. It also means small per-claim differences can grow into real money.
Here’s a second illustration, again with hypothetical numbers. Suppose a 10-physician group bills about 1,500 level 4 established-patient visits per physician each year to payers that run visit-level review. If 10% of those visits are paid one level lower, and the difference between the two levels averages $40, the group collects about $60,000 less in a year. Nobody would chase a $40 variance on a single visit. Across a year, it’s close to the cost of a full-time staff member.
Your own figures will differ by payer and contract. The exercise is still worth running with real data, because it shows where a small adjustment is turning into a budget line.
Some of it is worth contesting
Not every takeback or downcode is wrong. A careful review will confirm that some adjustments were fair, and those should be accepted and used to improve documentation going forward. The ones that don’t hold up can be disputed or appealed, and underpayments can often be corrected once the contract terms are documented clearly.
That work costs something. Premier has put the average cost of an appeal at $57.23, as reported by HFMA. So the goal is to spend effort where it’s likely to pay off, which starts with knowing which adjustments are worth challenging.
Appeals can also change how a payer treats a practice over time. The American Academy of Otolaryngology-Head and Neck Surgery reported that under Aetna’s program, practices whose appeals succeed 75% of the time are removed from automatic downcoding. A group that consistently appeals the downcodes its documentation supports may be able to work its way out of that review.
Where specialty expertise changes the outcome
Much of this comes down to reading remittances well, and doing that well takes specialty knowledge. A coder who knows orthopedic global periods can tell whether a reduced post-op visit was a fair adjustment or a misapplied edit. A denial specialist who has seen a payer’s patterns for years will notice when the same code gets adjusted across dozens of claims in a month, and will treat it as one problem to raise with the payer instead of dozens of separate write-offs.
That’s the work our certified coders and clinical denial specialists do for specialty groups at ADEC Healthcare. We review remits by payer and reason code to separate valid adjustments from ones worth contesting. Appeals get built around the documentation a reviewer needs to see, and when a pattern points back to how visits are documented, our team takes it to the physicians as practical feedback so the next claim holds up. All of it happens inside your own EHR and practice management systems, with regular reporting you can check for yourself. You get faster answers on where revenue is slipping, plus a team that already knows what to do about it.
Where to start this month
A group that wants a clearer view of its post-payment revenue can begin with four measures, all pulled from data it already has:
- Post-payment adjustments by payer and reason code, reported monthly as their own line instead of folded into payments.
- Billed versus paid E/M level for your highest-volume visit codes, broken out by payer and rendering provider.
- Expected versus actual payment on your top 20 codes, using your current contract rates.
- Appeal volume and appeal success rate by payer, so you know where appeals are working and where they’re not being filed at all.
Even a rough first pass at these numbers usually shows where to focus. If you’d like help running that first review, or want to see how your remits compare with what your contracts and documentation support, talk with our team. We’ll walk through what we find with you and show you where the biggest opportunities sit.
Payers will keep refining how they review claims. Groups that measure their own post-payment activity, and act on it every month, will be in a much stronger position to keep the revenue they’ve earned in 2027.
About ADEC Healthcare
ADEC Healthcare works with physician groups to build the cash posting, A/R follow-up and clinical denials capacity that catches a takeback before it turns into a year-end write-off.
Sources
- TechTarget, Insurers deny less just to claw back more later: analysis (Sept 23, 2026)
- MGMA Stat, Days in A/R holds steady for most practices, but payer pressure persists in 2026
- MGMA Stat, Detecting and fixing leaks across the revenue cycle
- Aetna, E&M Program Claim and Code Review
- AAO-HNS letter to Aetna on E&M downcoding (Sept 3, 2025)
- HFMA, Battle of the bots intensifies over denials (Jan 30, 2026)
