Every benchmark, denial statistic, and cost figure published on this site should be traceable. This page documents where our numbers come from, how we decide what to publish, and how we correct errors.
Statistics on this site come from three tiers of evidence, always used in this order of preference:
Peer-reviewed studies, government datasets (CMS, KFF), and published surveys from recognized industry bodies — MGMA, HFMA, CAQH, Experian Health, Premier Inc., Kodiak Solutions, and the AMA.
Payer provider manuals, fee schedules, timely-filing policies, and prior-authorization requirements — taken directly from payer publications, not second-hand summaries.
Patterns observed across two decades of real billing operations. When a figure comes from operational experience rather than published data, we present it as a range and say so.
These are the figures that appear most often in our guides and benchmarks, with their sources:
| Statistic | Figure We Use | Source |
|---|---|---|
| Average initial claim denial rate | ~11.6% (range 10–12%) | Kodiak Solutions revenue cycle benchmarking; Experian Health State of Claims surveys; Change Healthcare Denials Index |
| Cost to rework a denied claim | $25–$118 per claim | MGMA (~$25 for physician practices); Premier Inc. survey ($43.84 average, up to ~$117 for hospital claims) |
| Share of denials that are preventable | ~85–90% | Advisory Board denial analytics; AHIMA denial-management literature |
| Annual industry cost of claim denials | Tens of billions of dollars (estimates range ~$20–50B depending on scope) | Premier Inc. (~$19.7B/yr in hospital administrative spend disputing denials); CAQH Index automation-savings analyses. Where we cite a single figure, it reflects the broader scope that includes physician practices and written-off revenue. |
| Clean claim rate target | 95%+ (top performers 96–99%) | HFMA MAP Keys; MGMA performance benchmarks |
| Days in AR benchmarks | <35 days best practice; 30–40 typical; specialty-specific ranges in our benchmark report | MGMA DataDive; HFMA MAP Keys; specialty society benchmarking |
| First-pass resolution rate target | 88–93% | HFMA MAP Keys; industry RCM benchmarking |
| Prior authorization as top denial driver | 23–30% of preventable denials | AMA prior-authorization physician surveys; Experian Health State of Claims; payer remittance (CARC) analyses |
| Marketplace / commercial denial variation | In-network denial rates vary widely by payer (some near 20%) | KFF Transparency in Coverage analyses of ACA marketplace plans |
| Timely filing limits by payer | Medicare 365 days; commercial typically 90–180 days | CMS claims processing manual; individual payer provider manuals (verified against payer publications at time of writing) |
Every guide follows the same process before it goes live:
Benchmarks are directional, not diagnostic. A "good" denial rate varies by specialty, payer mix, and state — a DME supplier and a primary care office should not hold themselves to the same number. Where possible we publish specialty-specific ranges rather than single figures. Your own remittance data is always a better guide than any industry average.
Payer policies change constantly. Timely-filing windows, prior-authorization lists, and credentialing timelines cited in our guides were accurate when written and dated, but you should always verify against the payer's current provider manual before acting.
If you find a figure on this site that is outdated, unsourced, or wrong, email hello@americanbillingassociation.com with the page URL. Verified corrections are made promptly and the page's "Updated" date is revised. We would rather fix a number than defend it.
The 2026 RCM Benchmark Report compiles these sources into specialty-by-specialty performance tables.