Ensemble Health Partners manages $46 billion in net patient revenue across 300 facilities and 35 health systems. Their 2025 Payer Trendscape report documents what their teams are seeing in real-time. The numbers aren't good for providers.
The CMS Two-Midnight Rule — clarified January 1, 2024 — mandates that hospital stays expected to span at least two midnights should be classified as inpatient. That rule now applies to Medicare Advantage plans. It's been over a year. MA plans are still not complying.
Ensemble's data across their client base shows traditional Medicare's average inpatient admission rate running at 85.9%. Given that the MA and Medicare patient populations are nearly identical clinically, you'd expect MA to land in the same range. Instead, MA plans are running at 81.6% — a 4-point gap that represents roughly $9,000 per wrongful denial.
Each wrongful denial of inpatient status saves the MA plan approximately $9,000 per case. Across hundreds of thousands of admissions annually, the math is significant — and deliberate. Without dedicated resources to flag and challenge non-compliant MA decisions, most hospitals absorb the variance.
The Two-Midnight compliance gap is one problem. The broader denial trend is another.
Over the past 12 months, Ensemble tracked inpatient denial rates across Medicare Advantage, commercial, and traditional Medicare. The divergence is striking:
These aren't just initial denials. MA final denial rates — the write-offs after appeals are exhausted — now stand at 4.4%, compared to 2.6% for commercial and 1.3% for traditional Medicare. MA plans are issuing 1.7 times more final denials than commercial insurers.
Authorization denials, medical necessity downgrades, reduced level of care determinations — all categories are moving in the same direction, and none of it reflects a change in patient acuity. It reflects a change in payer strategy.
The third trend Ensemble documents is the rise of requests for information — and what their data reveals should change how providers think about the intent behind them.
Payers are increasingly demanding clinical documentation before processing claims, ostensibly to validate medical necessity. The stated rationale: data integrity. The actual effect: cash flow disruption.
Ensemble's data shows 90% of RFI-triggered claims get paid as billed. The information didn't change the outcome. What it changed was the timeline:
| Payer | Non-RFI: Days to Complete Payment | RFI: Days to Complete Payment |
|---|---|---|
| Aetna | 36.8 | 193.8 |
| United Healthcare | 45.6 | 180.8 |
| BCBS | 37.3 | 164.7 |
| Cigna | 49.3 | 130.7 |
| Humana | 35.1 | 119.6 |
Aetna's RFI claims take an average of 193.8 days to reach complete payment. The non-RFI baseline is 36.8 days. That's a 157-day delay — on a claim that ultimately gets paid in full.
"Without a doubt, I wouldn't be emboldened to bring litigation against commercial payers or do the things we are doing if I didn't have the experts at Ensemble behind us." — Health System CFO, KLAS Survey Response, September 2023
Most hospitals operate on thin margins with limited cash reserves. A 5-month payment delay on a claim that should have been processed in 37 days isn't a documentation issue — it's a cash flow extraction strategy. Payers are collecting the float.
Ensemble's report identifies three KPIs that teams should monitor alongside admission ratios:
The 42% MA denial increase isn't happening in isolation — it's happening alongside constant policy changes from these same plans. Prior auth requirements, medical necessity criteria, and covered service definitions are being updated faster than most teams can track manually. Knowing what each MA plan actually requires before a claim is submitted is the only durable defense against denial surge.
RevCycleAI tracks payer policy changes daily across MA plans, commercial insurers, and Medicare — so your team doesn't find out about coverage changes in a denial letter.
Subscribe Free →Ensemble's Payer Trendscape isn't theoretical. It's production data from $46B in net patient revenue across 300 facilities. The trends it documents — MA denial acceleration, Two-Midnight non-compliance, and RFIs as deliberate delay tactics — are structural, not cyclical.
The RCM teams that will weather this are the ones tracking the right metrics, staffing physician advisory programs adequately, and knowing what payers require before the claim goes out — not after the denial comes back.