A HFMA survey of more than 200 hospital and health system leaders shows payer friction is rising, denials are reshaping relationships and AI is seen as a potential lever.
Revenue cycle leaders don’t need another reminder that the ground is shifting. They’re living it every day through denials that are multiplying, rules that change with little to no warning, and payer relationships that feel less like collaboration and more like constant negotiations.
That reality comes through clearly in a recent Healthcare Financial Management Association (HFMA) survey sponsored by R1. Over 200 respondents who are director-level or above from hospitals and health systems answered questions about payer-provider relationships, revenue cycle management and artificial intelligence.
The findings are blunt. When asked which external factor is the most significant revenue cycle challenge today, 76.5% pointed to changing payer tactics, including more denials and delays. That’s not just an annoyance. It’s a strain on providers.
A relationship shift that impacts providers
Provider–payer relationships may have been tense previously, but they were also, generally speaking, still functional. Now leaders describe relationships that are closer to a tipping point.
More than half of HFMA survey respondents, 58%, report that payer relationships have deteriorated over the past three years. Less than 10% say they’ve improved.
When healthcare leaders put words to the tone of provider relationships, the picture sharpens. Fifty percent call them “transactional” and 36% call them “contentious.”
That matters because “transactional” isn’t just a perception. It can mean slower resolutions, more follow-ups, more rework and more time spent trying to interpret what payers will reject today versus what they accepted yesterday.
Denials and reimbursement cuts: The two-front fight
When leaders were asked what’s driving change in payer relationships, two forces rose to the top:
- 44% cited increased denials and claim rejections
- 28% said payer tactics to reduce reimbursements
Administrative burdens and policy changes were also noted by 22%. In addition, 18% named collaboration issues with payers as a top factor and 14% cited contract negotiation challenges and rate pressures.
Taken together, this doesn’t just point to an increase in denials. It indicates that the underlying economics of collections are tightening at the same time the work needed to secure a payment is expanding.
‘Regulatory challenge’ now means ‘payer rules’
One of the most telling findings of the survey is that even when the questions are focused on regulatory challenges, payers still dominated the answers. In fact, 61.5% of leaders said their biggest challenge is keeping up with payer-specific rules and documentation requirements.
In other words, the most disruptive “regulation” isn’t always a new policy from Washington. It’s the constant churn of payer requirements that forces teams into checking, rechecking and chasing down documentation to ensure a claim is processed.
AI holds promise, but sticking points remain
Leaders aren’t dismissing AI. Nearly half believe AI will have some impact on improving payer-provider relationships.
At the same time, the survey shows most provider organizations are approaching AI as a patchwork of tools rather than a comprehensive operating model. Today, 40% view AI as point solutions for specific tasks such as prior authorization or coding.
By contrast, only 24% see AI as a critical end-to-end transformational strategy. About a quarter, 26%, say it’s too early to tell about the impact of AI and are still evaluating it, while 7% call it mostly hype.
Where do leaders believe AI fits best in their organizations right now? They point to highly manual, high-volume functions that could potentially be improved or automated with AI, such as:
- 5%: Prior authorization
- 5%: Coding
- 2%: Denial management
- 6%: Documentation improvement
When asked what they expect AI to deliver if implemented successfully, leaders say the top outcomes are:
- 66%: Reduce administrative burden
- 56%: Increase recoveries and cash flow
Notably, a majority are not convinced that AI will deliver cost savings or accuracy gains yet.
Top concerns and barriers blocking AI adoption
85%
Compliance risk associated with AI
32%
Lack internal IT resources to implement
26%
Integration with existing systems
Top skepticism when vendors claim AI
52%
want credible proof points or benchmarks
15%
worry about long or complex integration
14%
question whether AI was trained on relevant healthcare or RCM data
The path forward: Move from tools to a comprehensive system
The survey data points to a practical conclusion, which is that payer pressure is accelerating. Current playbooks that require more people, more manual work, and more appeals won’t scale or advance payer relationships.
AI can help relieve the burden, but not as a collection of disconnected fixes. Leaders are signaling they need a system-level approach that can interpret payer rules, prevent denials and automate decisions across the revenue cycle, without creating new compliance exposure.
