Healthcare providers are under increasing pressure to secure timely reimbursements for high-dollar services. As big claims and payer complexities continue to rise in 2025, practices must evolve their billing strategy or risk significant revenue disruption.
At MBC, we specialize in medical billing and coding solutions designed to tackle these exact challenges. Whether it’s claim denials, evolving payer policies, or prior authorization delays, our approach delivers results that protect your bottom line.
The Shift in Payer Behavior Around Big Claims
One of the most noticeable trends this year is how payers are tightening their policies around big claims and payer complexities. From surgical procedures to advanced imaging, insurance payers are demanding more documentation and issuing more denials than ever before.
1. Increased Denials for High-Value Claims
Payers are flagging claims over $10,000 for extra scrutiny. Without airtight documentation and precise coding, these claims face higher denial rates—creating cash flow interruptions and administrative strain.
2. AI-Driven Claim Reviews
Insurers are leveraging AI to assess claim validity. Unfortunately, these systems often auto-deny claims based on rigid logic that overlooks clinical context. This has added a new layer to payer complexities and increased the volume of appeals for high-dollar services.
3. Stricter Prior Authorization Requirements
Despite industry efforts to streamline the process, prior authorization has become even more cumbersome. Payers are implementing new digital portals, restricting approval windows, and requiring more robust medical documentation—especially for hospital outpatient departments and specialty practices.
Proactive Steps to Manage Big Claims and Payer Complexities
With claim success tied closely to payer behavior, it’s critical that providers adopt a strategic, data-driven approach to revenue cycle management. Here’s how MBC helps our clients stay ahead:
1. Analyze High-Value CPT Code Trends
High-reimbursement codes are often at the center of big claims and payer complexities. We help practices audit these codes for risk exposure and payer-specific guidelines to prevent denials before submission.
2. Use Denial Data to Build Smart Submissions
MBC tracks denial patterns by payer and procedure type. By identifying the most common red flags, we guide clients in tailoring documentation and coding strategies to match real-world payer behavior.
3. Automate and Escalate Prior Auths
Our team integrates real-time prior authorization tracking with escalation workflows to cut through payer delays. This helps reduce treatment hold-ups and improve the chances of first-pass approvals on high-value services.
4. Partner with a Dedicated Account Manager
Every MBC client works with a dedicated account manager who monitors payer complexities, reviews big claim statuses, and intervenes proactively when delays or denials occur. You’re never left navigating payer challenges alone.
Key Payer Changes Affecting Big Claims in 2025
- UnitedHealthcare revised its bundling policies for surgical care, creating new documentation hurdles.
- Cigna is piloting AI-based adjudication tools for claims over $10,000.
- CMS has expanded its OPD Prior Authorization list, impacting multiple specialties and outpatient services.
Why Choose MBC to Handle Big Claims and Payer Complexities?
Managing big claims and payer complexities isn’t just about billing—it’s about anticipating denials, understanding payer behavior, and making data-driven decisions. At MBC, we combine dedicated account management, custom reporting, and payer-specific insights to improve reimbursement outcomes for high-value services.
If your practice handles high-dollar procedures, we’ll help you submit smarter, escalate faster, and get paid sooner.
Looking to improve outcomes on your biggest claims?
Schedule a consultation today with MBC.
FAQs
Big claims refer to high-dollar insurance claims, often exceeding $10,000, typically tied to complex procedures like surgeries, advanced imaging, or chronic care treatments. These claims are more likely to be audited, delayed, or denied by payers due to their financial impact.
Insurance payers delay or deny big claims due to issues such as incomplete documentation, incorrect coding, lack of prior authorization, or failing medical necessity requirements. Payers often review these claims more rigorously, especially with AI-driven systems.
To reduce denials on high-value claims, ensure complete documentation, accurate coding, and payer-specific compliance. Working with a billing partner like MBC helps implement claim scrubbers, denial tracking, and payer-specific protocols to increase clean claim rates.
Prior authorization is often a prerequisite for big claims, especially in surgical, imaging, and specialty care. Without timely approval, claims are likely to be denied or delayed. MBC provides real-time auth tracking to reduce turnaround time and prevent missed approvals.
MBC offers a proactive approach by combining dedicated account managers, denial analytics, CPT audits, and real-time payer tracking. We specialize in managing big claims and payer complexities to ensure faster payments and reduced revenue loss for healthcare providers.
