u/No_Paramedic_4881

Not a clinician. I spent the last week pulling the public datasets on US healthcare spending into one place (writeup with charts here) and I've hit the wall of what public data can tell me. Hoping the people who live inside this system can fill in the part I can't see.

Here's what I can see from the outside:

• Medicare Advantage plans deny 17% of initial claims. 57% of those denials are overturned on appeal (Health Affairs, via AHA).
• Hospitals spent $43B on payment collection in 2025. $18B of that on denial appeals alone.
• The average hospital runs 64 billing and admin FTEs, roughly 6.5% of workforce.
• Mark Cuban claimed on LinkedIn this weekend that hospitals pay 2% to 8% of revenue to RCM consultants.

That's the macro picture. What I can't see is the per-hospital reality:

1. On the denial side: when a claim gets denied and then overturned, what's the real all-in cost of chasing that overturn? Staff time, software, consultant fees, DSO impact, the whole bill. Is the 57% overturn rate driven by auto-denials on technicalities that clear easily, or is a meaningful share of it medical necessity fights that eat weeks per case?
2. On the RCM side: is the 2% to 8% Cuban quoted roughly right? And if your hospital outsources RCM, why? Is it genuinely cheaper than building internally, or is it that the denial game got so complex that specialist firms are the only ones who can keep up?
3. On the self-funded employer angle: Cuban's argument is that ~60% of commercial patients are really covered by self-insured employers, and hospitals could go direct to those employers and cut the carrier layer out. Has anyone at your shop actually tried direct-to-employer contracting? What broke, or why didn't it?

Not trying to sell anything. I'm a software person who got pulled into this trying to understand where $5T a year actually goes, and the answer public data gives me keeps pointing at a number I can't measure from outside: what it costs a hospital to operate inside this payment system. If any of that resonates, I'd genuinely like to learn.