Denial Rate Benchmarks for Physician Practices by Specialty

Physician practices lost an average of 11.8% of initial claims to denial in 2024, according to the MGMA 2024 Cost and Revenue Report, up from 10.2% just a few years prior. That single number sets the baseline against which everything else in this piece has to be measured, and it hides more than it reveals.

The Experian Health 2025 State of Claims survey found that 41% of providers now report denial rates at or above 10%, up from roughly 30% in 2022. That threshold matters because HFMA has long treated 10% as the ceiling for acceptable performance. So the share of practices operating above what used to count as a warning line has grown every year the survey has run. Kodiak Solutions' State of the Healthcare Revenue Cycle report, drawing on data from more than 2,300 hospitals and 375,000 physicians, found every tracked denial category rose by 0.2 percentage points year over year through early 2026. Telehealth-related denials spiked 84%, per MDaudit's 2025 Annual Benchmark Report, a sign that payer scrutiny has moved well past legacy billing categories into newer service lines that practices assumed were settled.

None of this traces back to one cause. Prior authorization denials actually declined in 2024, while other denial categories continued to climb, according to available industry reporting. A practice that has spent the last two years bracing for PA friction alone may be missing where its denials are actually coming from. A practice sitting at 10% today is not an outlier. It is sitting where a growing share of the industry now lands, and the ground has shifted underneath it without most billing offices noticing.

How payer type shapes the denial environment a practice actually faces

Traditional Medicare remains the lowest-friction payer in American medicine, and it is the fixed point against which every other payer type should be read. Medicare Advantage is the opposite story. MA denial rates have climbed substantially year over year and now sit well above traditional Medicare rates, according to Experian Health survey data. No other single shift in payer behavior matters more to a physician practice right now than this one.

The Revenue Synergy 2026 Report breaks this down by specialty, and the pattern holds without exception. Primary care runs 5.8% in MA versus 3.1% in traditional Medicare. Cardiology runs 8.2% versus 4.4%. Orthopedics runs 9.6% versus 4.9%. Oncology runs 12.7% versus 6.2%. Radiology runs 11.4% versus 6.8%. Behavioral health, the highest of the group, runs 14.1% versus 7.9%. Every specialty roughly doubles its denial exposure the moment the payer shifts from traditional Medicare to an MA plan. That means a practice's payer mix isn't a side detail in its denial rate, it's a multiplier sitting on top of whatever baseline its specialty carries.

Fee-for-service Medicaid is widely reported among the highest-denial payer categories, with other payer types ranging broadly in between. The available data consistently places traditional Medicare at the low end of the denial curve and fee-for-service Medicaid near the high end, with Medicare Advantage and commercial payers occupying the middle ground.

Some of this is also just automation getting sharper. Payer adjudication systems have grown more automated across the industry, and common front-end errors such as NPI mismatches, date-of-service discrepancies, and place-of-service errors increasingly trigger automatic denials with limited human review. Carelon Medical Benefits Management, the entity formerly known as AIM Specialty Health that manages prior auth programs for BCBS plans across multiple states, updated its clinical criteria guidelines as well, though the specifics of any Q2 2025 change affecting conservative treatment duration requirements for musculoskeletal and spine procedures couldn't be independently confirmed. The point stands regardless: a spike that looks like a front-end billing failure inside a practice may actually be a payer policy change nobody flagged. A practice that hasn't segmented its denial data by payer type has no way to tell the difference.

Primary care and internal medicine: the low-denial baseline and why it is eroding

Primary care sits at the bottom of the denial curve, running 8% to 12% according to the medibilling.app 2026 benchmark compilation, the lowest of any specialty tracked. Simple E/M coding and historically light prior auth exposure explain most of it. The Revenue Synergy 2026 data confirms the pattern at 5.8% in MA specifically, the lowest MA rate of any specialty in the report.

But the floor is not fixed. Prior auth requirements have started creeping into primary care through referral and imaging pathways that practices have had little historical reason to systematize, according to medicalbillersandcoders.com. These represent authorization demands that primary care practices have had little historical reason to systematize. The dollar exposure from PA denials can accumulate meaningfully at the per-physician level, a figure that's easy to miss at the practice level because no single denial looks alarming on its own.

High-performing practices across every specialty aim for total denial exposure under 5%, per industry benchmark standards. Primary care has the best structural shot at hitting that number of any specialty on this list. It is also, ironically, the specialty least likely to be actively tracking its denials by category, since the historical assumption that primary care doesn't have a denial problem is exactly what's letting the newer PA-driven denials slide by unmeasured.

Orthopedics: why a high-volume surgical specialty accumulates denial exposure across every step of the care episode

Orthopedics runs 10% to 18%, according to omnimd.com's specialty benchmark analysis, and the range itself tells a story: a multi-step surgical episode, from initial imaging through the procedure to post-op physical therapy and DME, gives a claim more places to fail. Revenue Synergy's MA figure of 9.6% reflects the multi-step nature of orthopedic care, where authorization and billing touch points multiply across the episode.

Orthopedic denials cluster heavily around bundling and modifier-related claim edits, according to medprecisionbilling.com's 2026 benchmark analysis. Both are technical denials. That's actually good news, in a limited sense, because technical denials respond to front-end claim scrubbing and modifier discipline in a way that clinical denials do not.

The bigger problem is policy-driven. Carelon (formerly AIM Specialty Health), which manages prior auth programs for BCBS plans across multiple states, has updated its clinical criteria guidelines, and practices may encounter denials on clinical scenarios that previously cleared authorization without issue. The resulting medical necessity denial exposure for a mid-size orthopedic group can be substantial, and when stacked against total annual PA denial exposure, the combined number can be significant at the practice level. Orthopedic practices need denial tracking broken out by payer, not a single aggregate rate, because a BCBS spike after Q2 2025 is a policy event that calls for a documentation and appeal response, not a billing office retraining.

Cardiology: high reimbursement values attract disproportionate payer scrutiny and automated claim editing

Cardiology runs 12% to 20%, per omnimd.com, higher at the top end than orthopedics, and the driver here is different: high procedure values draw more scrutiny, plain and simple. Payers apply more automated editing logic to cardiology claims because the dollars at stake per claim are larger. Revenue Synergy's 8.2% MA figure concentrates most heavily in cardiac imaging and electrophysiology.

A recurring, structural source of denials in this specialty is the National Correct Coding Initiative's Procedure-to-Procedure edit set, which applies automatically to cath lab claims. Diagnostic components that should be separately billable get denied outright when modifier 59 or the X-modifiers aren't attached correctly, according to medprecisionbilling.com. This isn't a one-time glitch, it's a recurring pattern that a billing operation either builds a systematic fix for or keeps absorbing claim after claim.

Prior auth expansion is also biting cardiology specifically through nuclear stress testing, cardiac MRI, and certain interventional procedures now requiring authorization on MA plans that didn't require it before, per medicalbillersandcoders.com's 2026 trend data. Annual PA denial exposure for a mid-size cardiology group can be substantial given the specialty's high authorization volume. Cardiology's high PA volume makes it especially exposed as payer adjudication systems grow more automated, since front-end errors can trigger denials before any human reviewer examines the claim. The diagnostic question every cardiology billing office needs to answer is what share of its denials are NCCI edit failures, fixable through modifier discipline, versus MA medical necessity denials that require a completely different clinical documentation and appeal path. Treating both the same way wastes staff time on the wrong fix.

Oncology: where per-denial dollar exposure and appeal value are highest

Oncology's MA denial rate sits at 12.7%, per Revenue Synergy 2026, concentrated in J-code drug claims and step-therapy edits tied to infusion services. These are specific, identifiable denial types, which is unusual for a specialty this complex, and that specificity is what makes them appealable.

The dollar exposure per denial is the real story here. A single denied biologic prior authorization puts $4,000 to $18,000 in revenue at risk, according to medicalbillersandcoders.com's 2026 analysis. That is not a rounding error on a monthly revenue report. Step therapy mandates for biologics and specialty injectables generate the highest per-claim denial values of any specialty tracked in this piece.

The counterweight is that oncology denials, once appealed with proper clinical documentation, get overturned roughly 78% of the time, per the same source. That overturn rate changes the entire calculus around whether working denials is worth staff time. A 65% no-rework rate, cited by sully.ai from broader industry estimates, does more damage in oncology than almost anywhere else, because every unworked denial in this specialty represents a five-figure loss, not a three-figure one. A 3-provider oncology practice carries $85,000 to $210,000 in annual PA denial exposure, the highest figure of any specialty in this benchmark set. Same-day denial triage and a standing clinical documentation protocol for PA appeals aren't nice-to-have process improvements in oncology. They're the mechanism by which a practice actually collects money it has already earned.

Behavioral health: the highest denial rates in physician billing and why payer structure is the root cause

Behavioral health carries the widest denial range of any specialty in this piece: 10% to 16% for practices with a standard payer mix, according to omnimd.com, but as high as 20% to 30% in the medibilling.app 2026 compilation. That spread almost certainly comes down to how concentrated a given practice's caseload is in MA and Medicaid plans, which runs especially high in behavioral health markets. Revenue Synergy's MA figure of 14.1% is the highest of any specialty tracked in its report.

Three distinct forces sit underneath that number, and they call for three different responses. Carve-out plans, where a separate entity administers behavioral health benefits apart from the medical plan, create eligibility and authorization routing failures that look like front-end billing errors but are actually built into the payer's structure. Parity law disputes arise when payers apply stricter medical necessity criteria to behavioral health than to comparable medical or surgical care, which is a regulatory compliance fight, not a coding fix. And credentialing delays, among the longest in any specialty, leave gaps where claims get denied purely on provider enrollment status while nothing about the clinical care was in question.

Many of these denials are policy-constrained rather than operationally fixable, per omnimd.com's analysis, which means the appeal strategy has to lean on parity law documentation rather than simple claim correction. Benchmarking gets genuinely complicated here. A behavioral health practice sitting at 15% denials could be performing at or above market if its book of business is MA-heavy. The same 15% at a practice dominated by traditional Medicare patients points to a real operational problem that needs fixing.

Chiropractic and physical therapy: where Medicare modifier logic and medical necessity documentation create chronic denial exposure

Chiropractic and physical therapy run 15% to 20%, per medibilling.app, with the high end showing up wherever Medicare modifier logic breaks down. This exposure is heavily Medicare-driven and distinct in character from PA-related denials elsewhere on this list. The AT modifier requirement for chiropractic maintenance care, functional improvement documentation for physical therapy, and therapy cap exceptions all create a recurring documentation burden that has nothing to do with authorization or bundling.

These specialties do share the CARC 97 and CARC 4 exposure common to surgical fields, per medprecisionbilling.com, but layer medical necessity denials tied to justifying ongoing care on top of that. What stands out is the repetition: the same documentation gap generates the same denial code across hundreds of claims, month after month. That repetitive pattern means a front-end fix, correcting the documentation template once, pays off far more than chasing each denial individually after the fact.

Institutional memory matters more here than almost anywhere else in this list. Knowing which Medicare Administrative Contractor applies which Local Coverage Determination, and which commercial plan has adopted which therapy limitation, is knowledge that lives in a biller's head. When that biller leaves, the practice often doesn't realize the knowledge left with them until denials start climbing again.

Radiology and gastroenterology: two specialties where PA expansion is creating new denial exposure that did not exist two years ago

Radiology sits at 11.4% in MA per Revenue Synergy 2026, with diagnostic imaging carrying most of the medical necessity denials. Outpatient cardiac imaging authorization expansions on certain MA plans are the primary driver of the recent increase. What makes radiology's denial pattern harder to manage is that these claims often pass technical review cleanly and only get denied after adjudication, on necessity grounds. There's no modifier error or eligibility mismatch to catch at intake. The claim looks fine going out the door and comes back denied anyway.

Gastroenterology is facing a newer and faster-moving problem. Biologic prior auth requirements for inflammatory bowel disease treatments, including Humira, Stelara, and Entyvio, combined with new PA requirements on outpatient endoscopy under certain MA plans, have driven GI-specific PA denials up 44% year over year, according to medicalbillersandcoders.com's 2026 trend analysis. Two years ago, neither of these authorization requirements existed in most GI practices' workflows. Now they sit at the center of the specialty's denial exposure, and any practice still running its PA process on the assumptions that held in 2023 is going to keep losing claims it didn't expect to lose.