“I built this company from the clinical side of the table, not the billing side. I understand what a delayed biologic cycle means for a patient, and what an $18,000 clawback means for a practice’s ability to keep its doors open.”
OFFICE OF THE CHIEF MEDICAL OFFICER
John Cintron, MD
Founder & Chief Medical Officer | 25+ Years Board-Certified Clinical Practice
I started noticing it in my own practice, and then in conversations with colleagues across oncology, rheumatology, dermatology, and infusion medicine. A prior authorization that used to take a phone call now takes a week. A denial that used to come from a human reviewer now comes from an algorithm scanning for a missing lab value or a formatting inconsistency, with no clinical judgment involved at all.
The data caught up to what I was already seeing on the ground. Denial rates have climbed 31% as payers deploy automated adjudication filters. Physicians report burnout rates near 94%, driven almost entirely by administrative burden rather than the practice of medicine itself. Specialty groups absorb $720,000 to $4.8 million a year in at-risk revenue from denials that have nothing to do with medical necessity and everything to do with a technicality.
The part that troubled me most wasn’t the denials themselves. It was what I came to think of as the Appeal Paradox: practices win 80 to 90 percent of the appeals they file, and still lose money, because the staff time required to fight every winnable case doesn’t exist. The revenue was recoverable. The bandwidth wasn’t.
I founded Prior Authorization Solutions because I believe this is a solvable problem, not an inevitable cost of doing business. PAS audits clinical documentation against live, current payer criteria before a request is ever submitted, catching the errors that trigger denials before they happen, rather than fighting them after the fact. My goal with PAS is to give physicians and their teams back what this system has been quietly taking: time, revenue, and the ability to focus on patients instead of portals.
Every specialty practice’s denial exposure looks different depending on payer mix, procedure volume, and appeal capacity. Request a complimentary financial audit and our team will model your practice’s current denial-driven revenue exposure against your actual claims data.
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