HealthTech Hard 3,600/mo

Prior Authorization Automation

Automate prior auth submissions, status tracking, and appeals for medical procedures. Reduce prior auth processing from 3 days to 3 hours and stop losing revenue to authorization delays.

InsuranceAutomation
MRR Potential
$15K–$60K
Time to MVP
12–16 weeks
Search Volume
3,600/mo
Market Size
$4.2B

The Problem

Prior authorization takes an average of 14 business hours per request. 94% of physicians report care delays from prior auth. Practices spend $68K per physician annually on prior auth administration. 30% of prior auths are initially denied. Tracking prior auth status across 20+ payers requires daily phone calls. CMS finalizes Prior Auth Rule requiring electronic processing by 2026.

The Solution

AI-powered prior authorization platform that auto-fills forms from clinical documentation, submits electronically to payers, tracks status in real-time, generates appeals for denials, and predicts approval probability before submission.

Target Audience

Specialty practices requiring prior auth for most procedures (orthopedics, oncology, radiology), hospitals processing 500+ prior auths per month, and prior auth outsourcing companies managing authorizations for multiple practices

Key Features

1
AI form completion extracting clinical data from notes for auth submission
2
Electronic submission to 100+ payers via payer portals and X12 278
3
Real-time status tracking dashboard showing all pending authorizations
4
Denial prediction scoring auth requests by likelihood of approval before submission
5
Appeal letter generation with AI analyzing denial reasons and clinical evidence
6
Staff productivity analytics showing auth volume, approval rates, and turnaround time

Market Opportunity

Market Size
$4.2B — Prior authorization technology growing at 24.5% CAGR
Monthly Searches
3,600/mo
MRR Potential
$15K–$60K
Why Now?

CMS Prior Auth Rule mandates electronic processing by 2026. Physicians are demanding relief from prior auth burden. AI can extract clinical data for form completion. Payer electronic submission APIs are expanding. $68K/physician annual cost is unsustainable.

Revenue Model

Per-auth: $15/submission (vs $68 manual cost), $25/appeal. Platform: $299/mo (up to 100 auths/mo), $599/mo (500 auths), $999/mo (unlimited + API). Annual: 20% discount.

Competitive Landscape

CoverMyMeds (McKesson)

Prior auth. Free for Rx, paid for medical, market leader in pharmacy PA

Cohere Health

Prior auth AI. Enterprise pricing, payer-focused, growing rapidly

Infinitus

AI phone agent for prior auth. AI calls payers, well-funded

Manual phone/fax

14 hours per auth, $68K/physician/yr, 30% denial rate, care delays

Recommended Tech Stack

Next.jsPythonPostgreSQLOpenAI APIX12 278 EDIPayer portal APIsStripe

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