This report compiles verified benchmark data from the leading healthcare revenue cycle research organizations. Use it to compare your practice's performance against industry averages, top quartile, and best-in-class thresholds across the metrics that matter most to your bottom line.
MGMA establishes ≤40 days as the standard benchmark for most physician practices. Best-in-class is ≤30 days. Alert threshold: >50 days signals systemic AR management failure.
| Specialty | Industry Avg | Top Quartile | Top 10% | Primary Variance Driver |
|---|---|---|---|---|
| Primary Care / Family Medicine | 30–38 days | 25–30 days | <22 days | High volume, lower complexity |
| Cardiology | 35–45 days | 28–35 days | <28 days | Prior auth for imaging/procedures |
| Orthopedics | 38–48 days | 30–38 days | <30 days | Surgical auth, implant billing |
| Behavioral Health | 40–55 days | 30–40 days | <30 days | Payer credentialing gaps, auth burden |
| DME | 45–65 days | 35–45 days | <35 days | HCPCS coding, medical necessity docs |
| Pain Management | 38–50 days | 28–38 days | <28 days | Controlled substance audit risk, modifiers |
| OB/GYN | 32–42 days | 25–32 days | <25 days | Global billing periods, mixed payer |
| Neurology | 38–50 days | 30–38 days | <28 days | Neurodiagnostic coding complexity |
| Oncology | 40–55 days | 30–40 days | <30 days | Drug infusion prior auth, high-cost claims |
| Dental (medical crossover) | 35–50 days | 28–38 days | <28 days | Medical necessity documentation |
Sources: Revenue Synergy 2026 Specialty Benchmarks; MGMA Cost and Revenue Glossary; MD Clarity RCM Metrics Database
A clean claim passes all edits and is accepted for adjudication on first submission. The HFMA MAP target is 95%. 68% of providers say clean claim submission is harder in 2025 than the prior year (Experian Health 2025 State of Claims, n=250 RCM leaders).
| Specialty | Industry Avg | Top Quartile | Top 10% |
|---|---|---|---|
| Primary Care | 92–95% | 96–97% | 98%+ |
| Cardiology | 90–94% | 95–96% | 97%+ |
| Orthopedics | 89–93% | 95–96% | 97%+ |
| Behavioral Health | 88–92% | 94–95% | 96%+ |
| Pain Management | 88–93% | 95–96% | 97%+ |
| Oncology | 87–92% | 94–95% | 96%+ |
| Radiology | 91–95% | 96–97% | 98%+ |
| OB/GYN | 91–94% | 95–96% | 97%+ |
| Neurology | 89–93% | 95–96% | 97%+ |
| DME | 85–90% | 92–94% | 96%+ |
Sources: Revenue Synergy 2026; HFMA MAP Keys; Experian Health 2025 State of Claims
| Payer | Initial Denial Rate | Final Denial Rate (Post-Appeal) | Notes |
|---|---|---|---|
| Medicare FFS | 7.38% improper payment rate | ~2–3% | CMS FY2024 Improper Payments data |
| Medicare Advantage | 15.7% | ~6.7% (57% overturned on appeal) | KFF 2024 MA Data; AI-driven denials rising |
| Medicaid (FFS & MCO) | 16.7% | ~6% (44% overturned) | Aptarro 2026 |
| ACA Marketplace | 19–20% | ~8–10% | 9-year high (KFF 2023) |
| Commercial/Private | 13.9–15% | ~3% final | Rose from 8% to 11%+ (2021–2023) |
| Specialty | Avg Denial Rate | Top Quartile Target | Top 10% Target |
|---|---|---|---|
| Primary Care | 7–10% | <5% | <3% |
| Cardiology | 10–13% | <6% | <4% |
| Orthopedics | 12–15% | <7% | <5% |
| Behavioral Health | 15–18% | <8% | <6% |
| Oncology | 13–18% | <7% | <5% |
| Pain Management | 12–16% | <7% | <5% |
| Neurology | 10–14% | <6% | <4% |
| OB/GYN | 8–12% | <5% | <3% |
| Radiology/Imaging | 12–14% | <6% | <4% |
| DME | 14–20% | <9% | <6% |
Sources: Kodiak Solutions 2024 RCM Analytics; O STAFF Solutions 2025; Aptarro 2026; KFF 2024
Net Collection Rate = Payments ÷ (Charges − Contractual Adjustments). This is the single most important billing KPI — it shows what percentage of what you're owed actually gets collected. Alert: below 90% signals significant revenue leakage.
| Specialty | Industry Avg | Top Quartile | Top 10% | Key Notes |
|---|---|---|---|---|
| Primary Care | 94–96% | 96–97% | 97%+ | Straightforward coding boosts rate |
| Cardiology | 93–95% | 96–97% | 97%+ | Procedure mix drives variance |
| Orthopedics | 92–95% | 95–97% | 97%+ | Implant write-offs drag average down |
| Behavioral Health | 88–93% | 94–95% | 96%+ | High self-pay + no-show leakage |
| OB/GYN | 93–95% | 96–97% | 97%+ | Global period management critical |
| Neurology | 90–94% | 95–96% | 97%+ | Neurodiagnostic complexity |
| Oncology | 90–94% | 95–96% | 97%+ | Drug infusion complexity |
| Pain Management | 90–94% | 95–96% | 97%+ | High-risk code audit exposure |
| DME | 85–90% | 92–94% | 96%+ | Highest leakage specialty |
Sources: MGMA DataDive Cost & Revenue; Medical Billers and Coders 2024; Revenue Synergy 2026
| Billing Model | Small Practice (<3 providers) | Mid-Size (4–10 providers) | Large Group (10+ providers) |
|---|---|---|---|
| In-House (fully loaded) | 10–15% | 7–10% | 5–8% |
| Outsourced | 6–9% | 5–7% | 3–5% |
| Outsourced (complex specialty) | 8–12% | 7–9% | 5–7% |
Sources: Best Medical Billing 2025; Neolytix 2026; MBW RCM 2024; Optivate Health 2024; 247 Medical Billing Services
| KPI | Industry Average | MGMA/HFMA Target | Top Quartile | Top 10% |
|---|---|---|---|---|
| AR >120 Days (% of total AR) | 12–15% | <10% | <8% | <5% |
| AR >60 Days (% of total AR) | 25–35% | <25% | <20% | <15% |
| First-Pass Resolution Rate | 82–87% | 90%+ | 93–95% | 95–98% |
| CARC Code | Description | Frequency | Prevention |
|---|---|---|---|
| CO-16 | Missing/incomplete/invalid information | #1 most common — 26% of denials | Pre-submission claim scrubber; demographic verification |
| CO-4 | Modifier invalid for procedure billed | Top 5; high in surgical specialties | Modifier rules engine; coder training on -25, -59, -51 |
| CO-97 | Payment included in allowance for another service | Top 3; high in cardiology, surgery | CCI edit check; NCCI bundling awareness |
| CO-22 | COB issue — coordination of benefits | Significant in dual-coverage patients | COB verification at eligibility check |
| CO-11 | Diagnosis inconsistent with procedure | Common in behavioral health, ortho | ICD-10 specificity; LCD/NCD alignment |
| CO-50 | Not deemed medically necessary | Growing — affects MA heavily | Medical necessity documentation; LCD adherence |
| CO-29 | Timely filing deadline exceeded | ~5% of all denials — 100% preventable | Automated filing deadline tracking by payer |
| CO-109 | Claim not covered by this payer | Front-end eligibility failure | Real-time eligibility verification |
| Payer | Avg Processing Time | Initial Denial Rate | Timely Filing Window |
|---|---|---|---|
| Medicare FFS | 14 days (electronic), 29 days (paper) | 7.38% | 365 days from DOS |
| Medicare Advantage | 14–30 days (varies) | 15.7% | 365 days (most plans) |
| Medicaid FFS | 30–45 days (state-dependent) | 16.7% | 90 days–12 months (state-dependent) |
| UnitedHealthcare | 15–30 days | 13–17% | 90–180 days commercial |
| Aetna | 15–30 days | 12–16% | 120 days most commercial |
| Cigna | 15–30 days | 11–15% | 90–180 days |
| Humana | 14–28 days | 12–16% | 90 days (strictest major payer) |
| BCBS (varies by state) | 15–30 days | 10–14% | 60 days (WY) to 2 years (AL) — verify by state |
Sources: CMS MLN Matters MM3557; KFF 2024 MA Data; Aptarro 2026; HFMA 2025; BellMedEx Timely Filing Guide
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