Revenue cycle leaders are managing an environment that is changing faster than most organizations can adapt, and their team knows it.
For many, the most acute pressure comes from payers deploying artificial intelligence to review and deny claims at a scale and speed that provider operations aren’t built to match. But the threat landscape is broader than any single issue: documentation integrity, workforce burnout, organizational fragmentation and the slow accumulation of invisible revenue losses all compound the core problem of getting paid for care in a system defined by administrative friction.
Becker’s asked revenue cycle leaders from major health systems to identify the most dangerous trends shaping their field. Their answers cluster around 10 challenges.
1. Payers’ AI is outpacing providers’ defenses. Payers are deploying automation to review 100% of claims. Most health systems still manually review only a fraction of payer activity. Closing the gap requires providers to build their own AI and predictive analytics capabilities, integrated tightly across clinical documentation, coding and denials management.
“The greatest threat is not autonomous coding replacing staff,” said Tami McMasters Gomez, executive director of mid-revenue cycle at UC Davis Health in Sacramento, Calif. “It is payer automation denying or delaying reimbursement faster than providers can identify and respond to it.”
2. Automating broken processes only makes them break faster. AI doesn’t fix bad data or poorly designed workflows. It scales them. The rush to adopt new technology can paper over operational problems that should be fixed rather than accelerated, and when the scale of automation is large, so is the scale of the errors it produces.
“If the underlying process is broken, automating it just means you can make the same mistake much faster and across thousands of claims instead of a handful,” said Shannon Cameron, COO of revenue cycle and AFS at Harvard Medical Faculty Physicians in Boston.
3. AI adoption without governance is its own risk. Pressure to move fast on technology is creating governance gaps that can expose organizations to compliance risk. AI-assisted documentation and coding tools introduce real liability when outputs aren’t carefully reviewed by humans who understand what the tools are doing and when a tool is introduced without clear accountability for accuracy and results.
“AI-assisted documentation and coding tools are particularly concerning because errors can create compliance, reimbursement, and audit risks if they’re not carefully reviewed by a human,” said Dawson Ballard Jr., coding auditor and educator at Rush University Medical Center in Chicago.
4. Silent downcoding is eroding revenue no one can see. Formal denials are trackable. But a growing payer tactic is downcoding, which means the revenue loss doesn’t appear in traditional denial reports.
“The newer, and potentially more concerning development is payer downcoding and reimbursement reduction without formal denial activity leading to decreased yield and net revenue erosion,” said Aaron Klein, senior vice president of financial operations and supply chain at Carle Health in Urbana, Ill. “These payment reductions often do not appear in traditional denial reports making revenue leakage difficult to identify.”
5. Prior authorization is consuming capacity providers don’t have. Prior authorization requirements continue to expand, and the administrative resources needed to manage them are disproportionate to what most providers can sustain. A case can be clinically appropriate, successfully performed, and well-documented, and a single authorization failure can still mean the organization is never reimbursed.
“Expanding prior authorizations, automated denials, and complex reimbursement rules create financial strain, delay care, and increase clinician and workforce burden,” said Kathleen Moriarty, MSN, RN, senior director of case management at Ann & Robert H. Lurie Children’s Hospital of Chicago.
6. Fragmentation means no one owns the full problem. When departments solve their own revenue cycle problems in isolation, the organization accumulates cost, compliance risk, and redundant technology spending with no single owner tracking the combined financial impact of those disconnected decisions.
“The most dangerous trend in the healthcare revenue cycle is fragmentation, where departments are solving individual problems without clear ownership of the end-to-end financial impact or patient experience,” said Lindsay Bennet, chief revenue officer at Centerstone in Nashville, Tenn.
7. The real denial nobody measures: care that never happens. The industry has sophisticated systems for tracking denials after claims are submitted. It has almost nothing for measuring the care patients abandon because they can’t navigate the administrative process and abandoned care is both a clinical failure and a financial one.
“When patients abandon treatment because they can’t afford it, their authorization was delayed or denied, they couldn’t navigate the process, or the administrative burden simply became too great, the consequences of care that never happens may be the most important denial we’re not measuring,” said Beth Carlson, chief revenue officer of the Ohio State University Wexner Medical Center in Columbus.
8. Documentation gaps are becoming payer targets. As payers deploy more sophisticated AI to audit claims, every inconsistency or weakness in the medical record becomes a potential target. The same documentation practices that have always been important now carry heightened consequences: a gap that once passed through the system is now more likely to surface in a post-payment audit.
“It’s no longer enough to focus on getting claims paid,” said Shelly Thompson, MSN, RN, senior director of clinical revenue cycle and revenue integrity at Sentara Health in Norfolk, Va. “We also have to be prepared to defend the care that was provided and the reimbursement that was earned long after the claim has been processed.”
9. Administrative burden is burning out the workforce. The same administrative complexity that drives revenue risk also drives turnover among the people managing it. Revenue cycle teams are absorbing more volume, more sophisticated denials, and more complex payer rules, frequently without a corresponding increase in resources.
“As administrative burden continues to grow, it threatens not only financial sustainability, but also workforce resilience and access to care in the communities that depend on it,” said Tanya Sanderson, RN, senior director of denials management at Stanford Health Care in Palo Alto, Calif.
10. Reimbursement has become too unpredictable to plan around. Shifting payer policies, evolving value-based care arrangements, changing government reimbursement methodologies, and increased claims scrutiny have made reimbursement difficult to forecast, which makes every strategic investment decision harder to justify and more likely to be misaligned with where the revenue environment ends up.
“Health systems must make strategic investments in staffing, technology, and patient access without a clear understanding of how reimbursement rules may evolve or how payer behavior may change,” said Austin Palmer, director of business analytics and data science at AdventHealth in Altamonte Springs, Fla.
