The Problem: Unpaid or Underpaid Insurance Claims
Hospitals face two very different revenue challenges:
- Medicare/Medicaid Underpayments (~$130B annually): Locked-in shortfalls due to CMS reimbursement rates. These cannot be negotiated.
- Commercial Claim Denials (~15% of claims denied initially): Roughly half are eventually overturned after expensive appeals, while the rest remain unpaid, shifted to patients, or written off.
For hospitals, this translates into hundreds of millions of dollars at risk each year:
- An average-sized health system (~$240M NPR) sees ~150,000 unpaid claims annually.
- Even a 1% improvement in collections equals $2.4M per year for an average hospital — and nearly $9.5M for large systems ($950M+ NPR).
The financial toll is massive:
- $334–$462B in initially denied claims nationwide (inflation-adjusted from a Change Healthcare study).
- $20–25B spent annually on administrative costs to fight denials.
The Solution: Generate for Hospitals
Generate uses Agentic AI workflow cards to stop revenue leakage before it happens. By working directly at the EDI file level across multiple EMRs, Generate eliminates the friction of integration and quickly surfaces actionable insights.
What it does:
- Query complex claim data instantly — no structured inputs needed.
- Pinpoint claim errors and payment gaps (like incorrect codes, shadow denials, and underpayments).
- Analyze historical payments vs. contracts to uncover systemic patterns.
- Automate workflows like appeals, audit prep, and reporting.
- Accelerate appeals by generating letters, cross-checking payer rules, and resubmitting fast.
“This is a playground of answers to all the questions healthcare leaders are asking.”
— Dr. F.X. Campion, MIT Research & Engineering
Real-World Results
- At the very first hospital onboarded, Generate uncovered $17.4 million in unpaid claims — money already earned but trapped in payer complexity.
- One benchmarking study found that unresolved claim denials equal up to 5% of net patient revenue (NPR). For an average hospital with $240M NPR, that’s $12M per year in avoidable losses.
- Across the U.S., insurers deny 450 million claims per year on first pass. Hospitals are leaving millions on the table due to opaque payer practices.
Impact & ROI
Generate delivers measurable, recurring financial outcomes:
- Recover underpaid claims and reduce denial write-offs.
- Target recovery opportunities with precision, based on historical data, contracts, and payer performance.
- Negotiate payer contracts armed with real-world benchmarks and peer comparisons.
- Accelerate cash flow and reduce administrative overhead.
- Fund critical staff — turning recovered dollars into nurses, doctors, and frontline resources.
“The data and dashboards have been invaluable. We now understand our true financial picture, can hold vendors accountable, respond to audits, and recover underpaid claims.”
— Robin Cetti, Director of Decision Support & Revenue Integrity, Hutchinson Regional Health System
Bottom Line
Hospitals are fighting uphill battles against payer complexity. But with Generate:
- Denials aren’t just managed — they’re prevented.
- Revenue loss is plugged, margins are protected.
- Every recovered dollar becomes fuel for hospital stability and growth.
For struggling hospitals, this is AI that could save jobs — and in some cases, save the hospital itself.
