Case study · Healthcare admin / RCM
Prior-auth packet assist without auto-submit theater
Multi-site specialty group · Houston metro (TMC-adjacent admin pattern)
Primary metric: staff hours on packet assembly · Results under NDA
- Industry
- Healthcare admin / RCM
- Horizon
- 90-day pilot
- Systems
- EHR exports, portals, DMS, workqueues
- Primary metric
- Packet assembly hours · NDA
Situation
Prior-authorization volume was stacking. Experienced staff spent mornings hunting charts, attaching the same artifact types, and reworking submissions kicked for incompleteness. Leadership had already bought tools that didn’t change the queue.
Constraint
HIPAA. PHI minimization. Payer rules vary. Clinical judgment stays with licensed staff. IT would not approve shadow IT or consumer AI tools. Needed BAA-ready vendors and an audit story. See Security posture.
What we shipped
- Packet checklist standardization by payer/procedure cohort (thin slice first)
- Assistive assembly from approved EHR/document sources
- Completeness flags before human submitter review
- Workqueue integration pattern ops already understood
- Enablement for submitters + quality reviewer role
Controls / human-in-the-loop
No autonomous submission to payers. Human review mandatory. Access logging. Environment separation. Written data-handling rules; no training on customer PHI without agreement. Security questionnaire completed pre-build.
Results
Under NDA until client-approved. Primary metric: staff hours on packet assembly in the pilot pod, baselined and reviewed with ops leadership. Secondary: incomplete packet rework on the in-scope cohort. No fabricated public hour counts.
What we refused to do
- “Auto-submit all auths” agent pitch
- Ambient clinical documentation scope creep mid-pilot
- Skipping BAA / security review to move faster
Start with one metric—not a 90-slide roadmap
Tell us where cost, throughput, or labor is stuck. We’ll tell you if a 2–4 week assessment is the right next step—or if it isn’t.