Healthcare automation › Prior authorization
Prior authorization automation
Prior authorization is the highest-touch, lowest-judgment work in the revenue cycle. We automate the submission, the status chasing and the rework across every portal you deal with, and leave your people the exceptions that actually need a human.
Book a teardownThe problem
For most laboratories and provider groups the real cost is not the staff time. It is the delay. Every day an authorization sits in a portal is a day of deferred revenue, and every manual touch is a chance to lose the claim entirely.
The pattern is consistent. Volume grows, the auth queue grows with it, and because the work is portal-bound and rules-heavy, the only lever anyone can find is headcount. Then three things happen at once:
Turnaround stretches
Work sits because the queue is longer than the day.
Consistency drops
Two coordinators handle the same payor differently, and only one of them gets it approved first time.
Ramp-up becomes the bottleneck
A new hire needs months to learn a dozen portals and the unwritten rules of each.
That last one is the trap. Productivity is sitting in individual expertise rather than in a process, so the organization cannot scale without hiring and cannot hire fast enough to scale. When leadership at one of our clients modeled the growth they were seeing, the answer came back as three times the billing staff. That was the moment they called us.
Scope
The portal work and the waiting: eligibility and benefit checks, requirement determination, submission, document attachment, status polling, and the write-back into your system of record. We do not automate clinical judgment or the peer-to-peer conversation.
The approach depends on the target. Where a payor offers a real interface or a standard transaction, we use it. Where the only route is a browser session, we drive the portal. Where the input is a faxed order, we read it first. Being tool-agnostic is the point. We are not selling you a platform license.
Everything runs with full audit trails, because in this work the audit record matters as much as the throughput. Every automated action is logged with its inputs, its outputs and the screen it acted on. Our security positions.
Proof
Yes: at a national cancer diagnostics laboratory, continuously since 2018. Prior authorization was one of the first functions we automated, and the program now processes about 150,000 transactions a month that used to be done by hand.
Within six months of the first deployment the client recorded a 300% increase in individual processing capacity, which eliminated the planned three-times hiring entirely. Denials fell 40% and appeal success improved 70%, largely because consistent submissions produce fewer avoidable rejections in the first place.
Now in its eighth year, the program still runs and still expands. That matters more than the launch numbers: most automation programs decay when portals change and nobody maintains them.
Measured 2018 to 2026 against the client’s pre-automation manual workflow.
Read the full case study →Engagement
Four stages over roughly eight to twelve weeks for a first workflow. You see working software in the first three weeks, not a slide deck at the end.
01
Teardown
Thirty minutes on your workflow, volume and payors. You get a one-page opportunity map ranked by hours recovered per week, whether or not you hire us.
02
Map and instrument
One to two weeks. We watch the actual work, count the touches, and pick the first workflow on volume and stability rather than on what is most annoying. We also find what will break.
03
Build the first workflow
Two to three weeks to something running in your environment against a real payor. Attended first, so your team stays in control while trust is being earned.
04
Widen and hand over
Additional payors and adjacent steps, plus the dashboards and runbooks your team needs to own it. The documentation means you are not trapped either way.
Objections worth raising
Prior auth automation has a bad reputation for good reasons. Here are the four failure modes we hear most, and what we actually do about each one.
Payor portals change constantly. Will this not break?
It will break. That is a maintenance question rather than a design question, and any vendor telling you otherwise has not run one of these programs for eight years.
What we do about it: build against real interfaces and standard transactions wherever a payor offers them, because those are far more stable than a browser session. Where we must drive a portal, we monitor for failure on every run and treat a break as a same-day incident with a named owner. Rules live in configuration rather than code, so a policy change is an edit rather than a release. Budget for maintenance from day one and it is a nuisance; assume it away and the program dies in month nine.
Our EHR is locked down and IT will not grant access.
Normal, and not a blocker. We work with the access your organization is willing to grant, in this order of preference: an existing integration or standards-based interface, a read-only service account, a report-based extract, or screen-level automation in an attended session using a credentialed user.
That last option needs no new integration at all, which is often what unsticks a security review. We bring the lifecycle documentation, the BAA and the subcontractor policy to that conversation so your security team is reviewing paperwork rather than inventing it.
We tried automation before and it broke.
Most failed programs failed for one of three reasons, none of which is the technology: nobody owned maintenance, the process was automated before it was standardized, or the first target was chosen for visibility instead of stability.
We standardize the workflow before automating it, which is unglamorous and is the actual source of the results. We pick the first target on volume and stability. And we name a maintenance owner in the statement of work. If the honest answer is that a workflow should be fixed rather than automated, we will say so.
Will this put our team out of work?
It has not, in any engagement we have run. At the diagnostics laboratory it eliminated planned hires rather than existing staff, and the people already there moved onto exception handling and complex cases, work that is harder, more interesting, and where a person is genuinely better than software.
We will not pretend automation never displaces anyone. The roles most exposed are the ones consisting entirely of copying values between two screens, and those are also the roles with the worst retention. Plan the redeployment before you deploy, and tell your team what the plan is.
Questions we get asked
How long until we see something working?
Two to three weeks for a first workflow running against a real payor in your environment. Full rollout across payors is typically eight to twelve weeks, depending on how many portals are in scope and how quickly access is granted.
Do you replace our billing system or clearinghouse?
No. We work inside the systems you already have, against the payors you actually deal with. No rip-and-replace and no twelve-month implementation, which is the main reason organizations choose us over a platform.
Is patient data involved, and how is it protected?
Yes. This work touches PHI by definition. We operate under a BAA with audit logging on every automated action, and where a model is involved, clinical text is de-identified before it reaches one. Our security posture.
What size organization is this worth doing for?
The economics work when a single workflow consumes more than roughly one full-time equivalent of effort per week. Below that, the maintenance overhead is hard to justify and we will tell you so.
What does it cost?
First workflows are typically scoped as fixed-fee projects, with an optional monthly maintenance retainer. We give you a number after a conversation, when we know what we are actually looking at. We do not charge per bot.
Is any of this AI?
Mostly not. The bulk of the value here is deterministic automation with no model involved. Reading unstructured documents is the one place a model reliably earns its place. Where AI fits.
Related reading
Service
Denial management automation
The other half of the same problem: what is recoverable once a denial has already happened, and how to win it.
See the service →Two minutes
Readiness check
Eight questions that tell you whether your auth workflow is ready to automate, and which part to start with.
Take it →Five minutes
ROI calculator
Three inputs and three numbers, with every assumption behind the math visible and adjustable.
Run it →Hub
Everything else we automate
Prior auth is one door. The same method applies to intake, credentialing, case assignment and reconciliation.
See the hub →Next step
Thirty minutes, your volume and your top payors. You leave with a one-page map of what is automatable, ranked by hours recovered per week, yours to keep either way.
Book a teardown