MA Plans Are Denying More. DSOs Still Don't Know Which Network Is Repricing Their Claims.

Ensemble Health Partners just published their 2025 Payer Trendscape — production data from nearly 300 facilities and $46 billion in net patient revenue. The headline finding: Medicare Advantage plans have increased inpatient denials by 42% in the past 12 months, while commercial and Medicare denial rates stayed flat.

That's a medical group and hospital story. But the same payers driving that denial acceleration are the ones DSOs are navigating every day — through umbrella PPO networks that quietly reprice claims and shift fee schedules without any transparency about which network is touching which claim.

The Same Payers. Different Angle.

When United Healthcare, Aetna, BCBS, Humana, and Cigna increase denial rates on the medical side, the mechanism is authorization and medical necessity. On the dental side, the mechanism is network repricing — and it's harder to see.

These plans don't reprice your claims directly. They route them through umbrella PPO networks — Zelis/Maverest, Careington, DenteMax, Connection Dental, DHA, Premier — where a "leased" fee schedule applies that you may never have negotiated and can't easily identify from the remit.

The result is the same: less revenue than you're owed. The difference is that with a denial, you know you've been shorted. With network stacking, you often don't.

RFIs: What a 193-Day Payment Delay Looks Like

Ensemble's data also surfaces the RFI pattern — requests for information that delay payment on claims that ultimately get paid anyway:

90% of those RFI claims still get paid as billed. The information request didn't change the outcome — it just held your cash for 100–190 extra days. Ensemble calls it what it is: an interest-free loan from the provider to the payer.

DSOs face a structural version of the same thing. When claims route through an umbrella network without your knowledge, you don't know you're being underpaid — sometimes for months or years — until someone maps the network path and compares it to what you negotiated.

The Information Asymmetry Is the Product

Ensemble's Trendscape is a medical RCM document, but the underlying dynamic it describes applies to dental just as cleanly:

Payers have more information than providers about what's happening to their claims. That asymmetry is intentional. It produces revenue for the payer and confusion for the provider.

On the dental side, the confusion lives at the network layer. Which umbrella network is touching this claim? What fee schedule applies? Is the repricing from your direct contract, or a leased arrangement you've never seen? Who authorized the network access?

Most DSOs can't answer those questions. Most DSOs don't know to ask them.

What to Do About It

Ensemble's recommendations for the medical side — monitor KPIs, staff physician advisors, negotiate better contract language — translate directly to the DSO playbook:

• Know which umbrella networks have access to your claims before a patient walks in the door
• Identify which fee schedule actually applies when claims are repriced — not just what your contract says
• Audit remittances for network-stacking patterns: same payer, different fee schedules, no clear explanation
• Use that data in contract renegotiations — payers respond to documented evidence of underpayment

Source: Ensemble Health Partners — Payer Trendscape 2025. Data from nearly 300 facilities across 30+ health systems, $46B net patient revenue.