Friday, March 13, 2026

A BCBS-commissioned study found AI-enabled clinical documentation and coding tools are driving upcoding across US hospitals — adding an estimated $663M in inpatient and $1.67B+ in outpatient spending nationally. AI "ambient listening" tools that record physician-patient conversations and auto-assign billing codes accounted for roughly 20% of a 9% total claims increase (1.8% net). BCBS is now establishing audit expectations for hospitals using AI coding.

Starting March 31, payers (MA plans, Medicaid managed care, CHIP, QHP issuers) must publicly post aggregated 2025 prior authorization metrics — approval/denial rates, appeals outcomes, average decision times. This is the first time payer PA performance data becomes transparent at scale.

Separately, the 72-hour expedited PA response requirement and 7-day standard response requirement are now in effect for 2026. Payers must have live FHIR-based PA APIs by January 1, 2027.

Industry denial rates, which sat at 13-15% in 2025, are projected to reach 15-17% in 2026 for commercial and Medicare Advantage plans. MA plan denials specifically have risen 56%. Commercial denials are up 20%+. Average rework cost: $47.77 (MA) and $63.76 (commercial). 22% of healthcare leaders report losing $500K+ annually to denials. 62% of RCM leaders cite denials as their top obstacle for 2026.