Build Automated Prior-Auth and Eligibility Verification Software

1. 1

   Pick the workflow where denials cost the most

   Prior-auth pain is worst where a denial is most expensive: surgical case cancellations (a wasted OR block) and infusion-drug denials (a drug worth tens of thousands of dollars). Start with one and build automation that prevents those specific failures. Solving the highest-dollar pain first makes the ROI undeniable.

2. 2

   Build eligibility and prior-auth automation

   The product verifies insurance eligibility and benefits automatically, determines whether prior authorization is required, submits and tracks authorizations, and flags problems before the case or infusion is scheduled. Because payer systems are fragmented and non-standard, robust integrations and fallbacks (including AI for reading payer responses) are the hard, defensible core. Reliability is the whole value.

3. 3

   Prove reduced cancellations and faster collections

   Quantify the outcome at a pilot facility: fewer canceled cases, fewer denied claims, faster collections. These are dollars, so the sales case writes itself when the pilot data is solid. Instrument the pilot to attribute the improvement to your software credibly.

4. 4

   Integrate with the EMRs facilities already use

   The product lives inside the facility's existing scheduling and billing workflow, so integrations with common ambulatory EMRs and clearinghouses are essential. Friction at integration is where deals die. Prioritize the systems your target niche actually runs on.

5. 5

   Price by subscription or per transaction

   Charge per-provider or per-location subscriptions, or per authorization processed, justified by the cancellations and denials avoided. Multi-site ASC and infusion operators are the highest-value buyers because they feel the pain at scale. Land one and expand across the portfolio.

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Best for: Health-IT founders who can build durable automation against messy payer systems

Not for: Not for someone who wants to run prior authorizations as a human-staffed service; that is the existing prior-authorization service card. Not for a founder unwilling to build against messy, non-standard payer systems, which is the hard part. And not for a generalist SaaS team with no revenue-cycle depth.