Medical Billing Reference
Current figures on claim denials, appeals, and administrative workflows, with the source and scope behind every number.
Last updated September 9, 2026
These figures are intended as a starting point for writers, healthcare leaders, and practices comparing the operational pressures behind billing work. They are not a promise of any practice’s results. Each number links to the original source so it can be checked and cited in context.
$258B
CAQH reported this estimate for U.S. healthcare in 2024. Its 2025 Index drew on data from more than 600 provider organizations and health plans representing 63% of insured lives.
Source: CAQH 2025 Index, published February 19, 202617%
The CAQH 2025 Index also reported a 9% reduction in medical administrative spend, showing the scale of efficiency gains tied to electronic workflows.
Source: CAQH 2025 Index, published February 19, 2026$21B
This is an industry-level estimate, not a projection for any individual practice. It highlights why eligibility, claims, and authorization workflows remain operational priorities.
Source: CAQH 2025 Index, published February 19, 2026496M
KFF found that 451 million of these claims, or 91%, were for in-network services. The figures cover qualified health plans sold through HealthCare.gov, not every U.S. health plan.
Source: KFF analysis of CMS transparency data for 2024, published March 24, 202619%
The rate varied considerably by insurer and state, from 3% to 36%. Claims that were denied initially but later resubmitted and paid are not included as denied in this measure.
Source: KFF analysis of CMS transparency data for 2024, published March 24, 202637%
Across in-network and out-of-network claims combined, the reported denial average was 20%. This is a Marketplace dataset, so it should not be treated as a benchmark for every practice or payer mix.
Source: KFF analysis of CMS transparency data for 2024, published March 24, 202625%
In the limited reason data insurers reported for 2024, administrative reasons were the second most common category. Nine percent were attributed to lack of prior authorization or referral, while 5% were attributed to lack of medical necessity.
Source: KFF analysis of CMS transparency data for 2024, published March 24, 2026<1%
KFF reported that insurers upheld 66% of the appeals they received. The data underscores the value of catching administrative and coverage issues before claims become aged follow-up work.
Source: KFF analysis of CMS transparency data for 2024, published March 24, 2026How to read these figures
The denial figures above are based on qualified health plans sold through HealthCare.gov in 2024. They include medical and prescription claims after a service was provided. They do not represent every payer, every employer plan, or pre-service authorization decisions.
The administrative workflow figures are national estimates from CAQH. They describe the broader healthcare system, rather than a specific specialty, state, or billing company.
For a practice, the most useful internal view is still its own mix of payer responses, denial reasons, aging balances, and timely-filing risk. ACP helps practices organize that work, follow up on aging accounts, and identify recurring claim issues that deserve attention.
Methodology and sources
ACP reviews this page roughly monthly, or sooner when a principal source publishes a material update. Last reviewed September 9, 2026.
ACP Billing. “Medical Claim Processing Statistics: 2026 Update.” Accessed September 9, 2026.
Link directly to a statistic using its heading in the page address, for example #in-network-denials.
Talk with ACP about claims, aging accounts, and the next practical step for your practice.