How we think about price, and what has to be true for it to be worth it

5 min read

This platform is priced per practice - your volume, payer mix and how much of the work you hand over all move the number, so we quote it against your actual schedule rather than publishing a rate card. What we can state plainly is the structure, the benchmark, and how to evaluate it. The 2023 CAQH Index puts a manual prior authorization at about $10.97 per transaction from the provider's side, and software in this category typically costs more per transaction than the labour it replaces. Anyone evaluating this should start from that fact rather than discover it after the conversation.

#The structure first

Unit	Charged	Note
Authorization decided	the full rate	Charged on the payer's determination, not on submission
Submission ended undecided	a reduced rate	Transmitted, then voided or payer-silent past the follow-up window. Our failures and vendor outages stay free
Eligibility check	a small per-check rate	High volume and cheap, deliberately
Document processed	free
Per seat	none
Implementation fee	none
AI model account	none	The platform holds one credential. No practice does vendor procurement to use the product

Eight outcomes are billed at zero: abstained, validation stopped, identity refused, payer unsupported, duplicate, release expired, our error, and vendor outage. Each is work performed and a decision made. Charging for them would put a price on the platform declining to do something wrong, and the incentive that creates points the wrong way.

#Why the labour comparison fails

Price outcome-based software against the CAQH labour figure and it loses: a coordinator's time per authorization costs less than software like this charges for the same transaction. Presented as a staffing saving, it is a losing argument, and no amount of framing fixes it.

So the case has to be that there is value per authorization that is not coordinator time, larger than the premium over manual cost. There are three candidates, and a practice should test them rather than accept them.

Procedures that are not lost: An authorization that pends and is never chased arrives at the service date undecided, and the procedure is rescheduled or delivered at risk. A specialty procedure is worth four figures - so preventing even a small number of these losses per year covers a per-transaction premium many times over. That is a measurable rate, and it is the first thing to measure in a pilot.
Capacity that cannot be hired: A practice that cannot recruit an authorization coordinator at any salary is not comparing against $10.97. It is comparing against the work not happening, or happening late. This is a common situation and it changes the arithmetic completely.
Revenue that arrives sooner: Days off turnaround means earlier scheduling and earlier collection. Whether that is worth anything depends on the practice's capacity constraint, which is a question with an answer.

What the CAQH number does not include

The $10.97 is labour. It excludes denials and rework, physician peer-to-peer time, and procedures delayed or written off for a missing authorization. The true cost of manual prior authorization is meaningfully higher than $10.97, but we do not have a defensible figure for how much higher, so this article does not supply one. It is worth obtaining for your own practice before deciding.

#What you still pay for separately

Your clearinghouse entitlement. You hold the Availity relationship and we submit beneath it, so the payer's record names your organisation. We take no margin on the payer transaction, and a practice already submitting claims already has this.
Your practice management and EHR licences, which you already hold.

There is no markup on either, which is unusual in this category and is the reason the price is one metered rate rather than a rate plus transaction fees.

#Two commitments in the billing code

Billing never blocks clinical work: An exhausted balance does not halt an authorization. Overage is permitted, flagged loudly and escalated on our side. There is no hard stop, and adding one later would mean arguing with the reasoning recorded at the top of the billing module. A prior authorization halted mid-flight over an invoice is a delayed procedure, and the patient did not choose the payment terms.
The rate is negotiable: Pricing resolves through three layers: fleet, alliance, practice. A negotiated rate for an alliance or a single practice is a data change rather than a different product, and it applies to everything downstream automatically.

#How to evaluate it honestly

Get your own volume
Authorizations per month, from your last ninety days. Everything else scales from this.
Measure the losses you currently absorb
Procedures rescheduled for a missing or late authorization, and claims denied for no authorization on services that had one. These are the numbers the price has to beat, and most practices have never counted them.
Watch the non-billable rate in a pilot
The platform records every zero-rated outcome. After a month you know what share of your volume we decline to submit, which tells you both your effective rate and something useful about your data quality.
Decide on evidence
If the losses you were absorbing do not exceed the premium, this is not worth buying, and a pilot is the cheapest way to find that out.

A note on what this article is

The structure above is read from the billing code, and the benchmark is cited to a published source; the platform's own rate is quoted per practice, from the request-pricing form on the landing page. No return-on-investment claim appears here, because we do not have measured outcome data to support one. When there is a pilot with real numbers, those numbers will say what they say.