FROM THE FRONT LINES

Dr. Amanda Foster’s medical assistant spent 6 hours on Thursday tracking down prior authorizations. Six. Hours.

Three phone calls to UnitedHealthcare. Two faxes to Cigna. One portal submission to Aetna. Four follow-ups on pending requests from two weeks ago.

Zero approvals.

One patient canceled their PT appointment because the auth hadn’t arrived. Another delayed surgery for two weeks. A third left to find a provider “with less hassle.”

This is the prior authorization crisis. And it’s about to get worse before it gets better.

On June 23, 2025, HHS announced that 50+ major insurers pledged to overhaul their PA processes, affecting 80% of Americans (over 250 million people). New rules take effect January 1, 2026—30 days from now.

72-hour response times for urgent requests. 7-day turnaround for standard. Real-time electronic approvals for 80% of requests by 2027.

Sounds great, right?

Here’s the trap: These are voluntary pledges with zero enforcement mechanism. Remember 2018, when insurers promised similar reforms? Nothing changed.

But here’s what WILL change: Medicare’s new WISeR Model brings prior authorization to Traditional Medicare in 6 states for 17 high-risk services. CMS’s Interoperability Rule mandates 72-hour/7-day response times starting January 1, 2026.

This newsletter exists to help you navigate what’s real, what’s theater, and what you must do in the next 30 days to avoid losing $15,000+ to PA denials.

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THE NUMBERS THAT MATTER

The Prior Authorization Crisis (2025 Verified Data)

⏰ 43 – Average PA requests per week per physician (Physicians Practice survey)

💰 $15 billion – Estimated savings over 10 years from PA reforms (CMS projection)

📊 93.6% – PA requests ultimately approved in Medicare Advantage (CMS 2023 data)

⚠️ 1 in 4 – Physicians report PA led to serious adverse events

🔴 61% – Physicians believe payers’ AI use is increasing denials (AMA, March 2025)

⏳ 12 hours – Average staff time lost weekly to PA administration per physician

💸 $3,000-$8,000 – Cost per denied PA claim (treatment delay, appeal costs, lost revenue)

📈 50 million – Prior authorization requests processed by Medicare Advantage in 2023

🎯 97% – Physicians say PA should be reimbursed for administrative burden

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WHAT ACTUALLY CHANGES ON JANUARY 1, 2026

The Three Parallel Tracks of PA Reform

TRACK 1: CMS Interoperability Rule (ENFORCEABLE)

Who it affects: Medicare Advantage, Medicaid managed care, CHIP, QHP issuers on FFEs

What changes:

 

• • 72-hour decision deadline for expedited/urgent requests (currently unlimited in many plans)

• • 7-day decision deadline for standard/non-urgent requests (currently 14-30 days)

• • Specific denial reasons required (no more vague “not medically necessary” rejections)

• • Public reporting of PA metrics (approval rates, turnaround times, denial reasons)

• • FHIR-based Prior Authorization API implementation (electronic submission encouraged)

Compliance date: January 1, 2026 (operational requirements), January 1, 2027 (API requirements)

Enforcement: CMS can impose penalties for non-compliance

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TRACK 2: Voluntary Insurer Pledges (UNENFORCEABLE)

Who pledged: 50+ major insurers (UnitedHealthcare, Aetna, Cigna, Humana, Kaiser, BCBS plans)

Coverage: Nearly 80% of Americans (250+ million people)

What they promised:

 

1. 1. Reduce PA volume – Eliminate low-value administrative requirements by Jan 1, 2026

1. 1. Continuity of care – Retain approved PAs for 90 days when changing plans

1. 1. Transparency – Provide clear denial explanations, publish performance dashboards

1. 1. Real-time decisions – 80% of electronically submitted PAs approved immediately by 2027

1. 1. Standardization – Uniform criteria and documentation requirements

Enforcement: ZERO. These are voluntary commitments with no penalties for non-compliance.

Historical context: In 2018, insurers made similar promises. Nothing changed. PA volumes increased 27% from 2018-2023.

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TRACK 3: Medicare WISeR Model (ENFORCEABLE, LIMITED SCOPE)

Who it affects: Traditional Medicare (Original Medicare, not Medicare Advantage) in 6 pilot states

States: New Jersey, Ohio, Oklahoma, Texas, Arizona, Washington

What changes: Prior authorization now required for 17 services “vulnerable to fraud, waste, and abuse”

Services requiring PA:

 

• • Lower limb prostheses

• • Power wheelchairs

• • Hospital beds

• • Noninvasive diagnostic services

• • Wound care (grafts, biologics)

• • Durable medical equipment

• • Select diagnostic imaging

• • Certain outpatient procedures

• • (Full list: 17 services identified by CMS)

Timeline: January 1, 2026 – December 31, 2031 (5-year pilot)

AI involvement: AI assists review, but licensed clinicians make final decisions (not machines)

Enforcement: CMS-run program with defined compliance requirements

Why Voluntary Pledges Fail

1. No Enforcement Mechanism

 

• • CMS can’t penalize insurers for breaking voluntary commitments

• • No fines, no sanctions, no consequences

• • Pledges are PR, not policy

2. Profit Incentive to Deny

 

• • Every PA approval costs payer money

• • Every PA denial delays treatment (and payment)

• • Payers profit from administrative friction

3. AI-Driven Auto-Denials

 

• • 61% of physicians believe AI is increasing denials

• • AI flags “high-cost” services for automatic rejection

• • Humans rubber-stamp AI decisions

4. “Shrinkflation” Tactics

 

• • Reduce PA on low-cost services (good PR)

• • Increase PA on high-cost services (protects margins)

• • Net result: Same administrative burden, worse for expensive treatments

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WHAT THIS MEANS FOR YOUR SPECIALTY

FOR CHIROPRACTORS: The Maintenance Care PA Trap

Current Reality: Medicare doesn’t require PA for chiropractic CMT codes (98940, 98941, 98942). Yet.

What’s Changing:

 

• • Medicare Advantage plans may add PA requirements for >12 visits annually

• • “Medical necessity” documentation standards tightening

• • Outcome assessment scores becoming mandatory for PA approval

• • Continuity of care transitions (patient changes plans mid-treatment)

The New PA Documentation Requirements:

☐ Initial Treatment Plan with measurable goals

 

• • Baseline VAS, ODI, or NDI scores

• • Specific functional limitations

• • Expected treatment duration (e.g., “12 visits over 6 weeks”)

• • Short-term objective outcomes

☐ Progress Documentation every 4-6 visits

 

• • Updated outcome scores showing improvement

• • Objective findings (ROM measurements, postural analysis)

• • Justification for continued treatment (not yet at maximum benefit)

☐ Re-authorization Request at 12-15 visits

 

• • Comparison to baseline (must show ≥15% improvement)

• • Updated treatment plan if continuing

• • Discharge plan if maximum benefit reached

The Denial Risk: If you can’t demonstrate measurable improvement with outcome scores, PA requests will be denied as “maintenance care” (not covered).

WeBill’s PA Service for Chiropractors ($5 per authorization):

 

• • Pre-submission documentation review (catch missing elements)

• • Outcome score tracking alerts (don’t forget to document)

• • Payer-specific PA submission (we know each plan’s quirks)

• • Prevents: $3,500-$6,000 average denial cost per patient

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FOR PHYSICAL THERAPISTS: The KX Modifier PA Nightmare

Current Reality: Medicare therapy threshold is $2,410 for combined PT/OT/SLP services. Beyond that, KX modifier + medical necessity documentation required. No formal PA… yet.

What’s Changing:

 

• • Medicare Advantage plans adding PA requirements for high-frequency PT services

• • KX modifier alone no longer sufficient—PA approval needed pre-service

• • Manual therapy (97140) specifically targeted for PA reviews

• • Time-based codes under scrutiny (8-minute rule violations trigger PA denials)

The New PA Documentation Requirements:

☐ Initial Evaluation with functional baselines

 

• • Measurable functional limitations (ambulation distance, ADL performance)

• • Standardized outcome tools (LEFS, DASH, NDI, Oswestry)

• • Treatment plan with specific goals and timeline

• • Expected frequency and duration

☐ Progress Notes every 10-14 days

 

• • Quantified improvement (e.g., “ambulation increased from 50 feet to 200 feet”)

• • Updated functional status

• • Justification for continued skilled care

☐ PA Request for High-Frequency Services

 

• • Typically triggered at $3,000 threshold or 20+ visits

• • Must demonstrate continued functional improvement

• • Document why skilled PT still required (vs. home exercise program)

The Timing Trap: PA requests take 7-14 days. If you hit the threshold mid-treatment course, patient care gets interrupted while waiting for approval. Uninterrupted treatment? Bill without approval and risk denial.

The 8-Minute Rule Complication: If your time-based coding isn’t perfect (documented start/end times, correct unit calculations), PA reviewers will deny the entire authorization based on “pattern of improper billing.”

WeBill’s PA Service for Physical Therapists ($3-$5 per authorization):

 

• • Threshold tracking alerts (know when you’re approaching PA requirement)

• • Pre-submission PA request 30 days before hitting $3,000 (prevents treatment gaps)

• • 8-minute rule validation (ensures coding accuracy before PA submission)

• • Prevents: $4,500-$8,000 denial cost per high-frequency patient

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FOR BEHAVIORAL HEALTH: The Telehealth PA Minefield

Current Reality: Behavioral health has highest PA burden of any specialty. Telehealth added complexity with October 1, 2025 in-person requirements.

What’s Changing:

 

• • PA required for most psychotherapy beyond 8-12 sessions annually

• • Telehealth services face additional PA scrutiny (compliance with in-person rules)

• • New G-codes for digital mental health (G0552, G0546-G0551) require PA

• • Continuity of care during plan changes (90-day PA retention pledge)

The New PA Documentation Requirements:

☐ Initial Authorization Request (typically 8-12 sessions)

 

• • DSM-5 diagnosis with justification

• • PHQ-9 or GAD-7 baseline scores

• • Treatment plan with specific goals

• • Modality justification (individual, group, family)

• • Telehealth vs. in-person rationale

☐ Re-authorization Request (every 8-12 sessions)

 

• • Updated PHQ-9/GAD-7 showing improvement

• • Progress toward treatment goals

• • Continued medical necessity justification

• • Discharge planning timeline

☐ Telehealth-Specific Requirements

 

• • Documentation of in-person visit within 6 months (or upcoming appointment scheduled)

• • Justification for telehealth vs. in-person

• • Technology access confirmation

• • State licensure verification (for cross-state telehealth)

The Continuity of Care Problem: Patient changes insurance mid-treatment. Old plan approved 12 sessions, patient used 6. New plan requires new PA from scratch (doesn’t honor previous approval). Treatment interrupted for 14-30 days while waiting for new PA.

The 90-Day Pledge: Insurers pledged to honor existing PAs for 90 days when patients change plans. But this is voluntary and unenforceable. Don’t count on it.

WeBill’s PA Service for Behavioral Health ($2-$5 per authorization):

 

• • Session tracking alerts (know when re-auth needed 30 days in advance)

• • Telehealth compliance verification (catch in-person requirement violations)

• • Multi-payer PA coordination (handles continuity issues when patient switches plans)

• • Prevents: $2,500-$5,000 denial cost per continued treatment episode

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FOR URGENT CARE: The WISeR Model Impact

Current Reality: Urgent care primarily deals with commercial insurance PA requirements (minimal Medicare PA exposure).

What’s Changing:

 

• • Medicare WISeR Model brings PA to Traditional Medicare for first time

• • 6 pilot states (NJ, OH, OK, TX, AZ, WA) affected immediately

• • 17 services now require PA (DME, diagnostic imaging, wound care, procedures)

• • Creates two-tier Medicare system (Traditional with PA vs. Medicare Advantage)

Services Most Likely to Affect Urgent Care:

 

1. 1. Noninvasive Diagnostic Services
      

       

      • • EKG interpretation
      • • Diagnostic ultrasound
      • • Spirometry
      • • (PA required if billed to Traditional Medicare in pilot states)

1. 1. Wound Care
      

       

      • • Application of skin substitutes
      • • Wound debridement
      • • Negative pressure wound therapy
      • • (High-fraud area, heavily scrutinized)

1. 1. Durable Medical Equipment
      

       

      • • Crutches, walkers, braces
      • • If urgent care dispenses DME, PA now required
      • • (Most urgent care refers out, so minimal impact)

The Two-Tier Problem: Patient with Traditional Medicare in Texas needs EKG. Urgent care must either:

 

• • Submit PA and wait 7 days (defeats purpose of “urgent” care)

• • Provide service without PA and face post-payment review + potential denial

The Post-Service Review Option: Providers can skip PA and accept post-service/pre-payment medical review instead. CMS reviews claim before paying. If denied, you provided free care.

WeBill’s Recommendation for Urgent Care:

 

• • Verify patient’s Medicare type at check-in (Traditional vs. Advantage)

• • If Traditional Medicare in pilot state, check if service requires PA

• • For non-emergent services on PA list, refer to primary care or specialist

• • For emergent services, document medical necessity thoroughly for post-payment review

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THE $2-$5 INVESTMENT THAT PREVENTS $3K-$8K DENIALS

The Prior Authorization Service ROI

What It Costs:

 

• • Simple PA (routine services): $2 per authorization

• • Moderate PA (multi-visit approvals): $3 per authorization

• • Complex PA (high-cost procedures, peer-to-peer): $5 per authorization

What It Prevents:

Denied Service	Average Cost	WeBill PA Service	ROI
Chiropractic 12+ visit series	$3,500	$5	700:1
Physical therapy high-frequency	$6,800	$5	1,360:1
Behavioral health continued sessions	$4,200	$3	1,400:1
Manual therapy course (PT)	$2,800	$3	933:1
Specialty referral procedure	$8,000	$5	1,600:1

Real Example: Physical therapy practice treats 30 patients monthly who exceed $3,000 threshold. Without PA tracking:

 

• • 30 patients × $5,000 average treatment cost = $150,000 total billing

• • 20% denial rate (common without PA) = $30,000 denied

• • Appeal success rate 40% = $12,000 recovered

• • Net loss: $18,000 monthly

With WeBill PA Service:

 

• • 30 PAs × $5 = $150 monthly investment

• • PA approval rate 95% = $142,500 approved

• • Denial rate 5% = $7,500 denied

• • Appeal success rate 80% (with proper documentation) = $6,000 recovered

• • Net loss: $1,500 monthly

• • Savings: $16,500 monthly ($198,000 annually)

• • ROI: 1,100:1

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YOUR 30-DAY ACTION PLAN

Week 1 (Days 1-7): Assess Current State

☐ Audit last 90 days of PA requests

 

• • How many PA requests submitted?

• • Average turnaround time by payer?

• • Denial rate on PA requests?

• • Most common denial reasons?

☐ Identify high-volume services requiring PA

 

• • Which services trigger PA most frequently?

• • Which payers require PA for your top services?

• • What documentation do they require?

☐ Calculate staff time burden

 

• • Hours per week spent on PA submissions?

• • Hours per week spent on PA follow-ups?

• • Hours per week spent on PA denials/appeals?

• • Cost: (hours × staff hourly rate) =$ ______

☐ Benchmark against goals

 

• • Current PA approval rate: ____%

• • Target PA approval rate: 95%+

• • Current average turnaround: ____ days

• • Target turnaround (post-Jan 1): 7 days standard, 72 hours urgent

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Week 2 (Days 8-14): Update Documentation Standards

☐ Chiropractors: Implement outcome assessment tools

 

• • VAS, ODI, NDI at initial, every 12 visits, discharge

• • Build into EMR templates

• • Train staff on consistent documentation

☐ Physical Therapists: Standardize functional goals

 

• • Measurable baseline documentation (ambulation distance, ADL performance)

• • LEFS, DASH, NDI, Oswestry integration

• • 8-minute rule time tracking accuracy

☐ Behavioral Health: Update treatment plan templates

 

• • PHQ-9, GAD-7 baseline and progress tracking

• • DSM-5 diagnosis justification

• • Telehealth compliance verification (in-person visit tracking)

☐ All Specialties: Create PA-ready documentation

 

• • Medical necessity language standard templates

• • Functional limitation quantification

• • Short-term and long-term goals clearly stated

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Week 3 (Days 15-21): Implement Tracking Systems

☐ Set up PA threshold alerts

 

• • Chiropractic: Alert at visit 10 (allows PA submission before visit 12)

• • Physical Therapy: Alert at $2,300 (before $2,410 cap, allows PA before $3K review threshold)

• • Behavioral Health: Alert at session 6 (before 8-session typical limit)

☐ Create payer-specific PA matrices

Payer	Services Requiring PA	Documentation Required	Submission Method	Turnaround Time
UHC	PT >$3K, chiro >12 visits	Outcome scores, treatment plan	Portal	14 days
Cigna	Manual therapy, psych >8 sessions	Functional goals, progress notes	Fax	10 days

☐ Automate PA submission reminders

 

• • Calendar alerts 30 days before PA needed

• • Staff assignment for PA preparation

• • Follow-up system for pending PAs

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Week 4 (Days 22-30): Partner or Automate

Option 1: In-House PA Management

 

• • Pros: Direct control, no per-PA fees

• • Cons: Staff time (12+ hours weekly), expertise gaps, no economies of scale

• • Best for: Large practices (10+ providers) with dedicated PA coordinator

Option 2: WeBill PA Service

 

• • Pros: $2-$5 per PA, specialty expertise, 95%+ approval rate, frees staff time

• • Cons: Per-transaction cost

• • Best for: Small to mid-size practices (1-10 providers)

What WeBill’s PA Service Includes:

 

• • Pre-submission documentation review (catch missing elements before denial)

• • Payer-specific submission (portal, fax, phone—we know each payer’s preferences)

• • Tracking and follow-up (we chase down pending PAs so your staff doesn’t have to)

• • Denial management (if PA denied, we handle the appeal with clinical justification)

• • Real-time alerts (you know PA status immediately, no waiting in limbo)

Option 3: Hybrid Approach

 

• • In-house for simple, routine PAs

• • Outsource complex, high-value PAs to WeBill

• • Best of both: cost control + expertise where needed

☐ Make decision by Day 30 (before January 1 implementation)

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WHAT HAPPENS IF YOU DO NOTHING

The 2026 PA Disaster Scenario

January 2026: New 72-hour/7-day rules take effect. Your practice hasn’t changed anything.

Week 1:

 

• • UnitedHealthcare rejects 3 PA requests for “incomplete documentation” (no outcome scores)

• • Average turnaround: Still 14 days (voluntary pledge ignored)

• • 2 patients cancel appointments due to PA delays

Week 2:

 

• • Cigna denies physical therapy PA for patient at $3,200 (you billed without PA, assuming automatic approval)

• • Denial reason: “Medical necessity not established”

• • You appeal. Cigna takes 30 days to respond.

Month 2:

 

• • 8 PA denials this month (same documentation gaps)

• • Staff spending 15 hours weekly on PA follow-ups (up from 12)

• • Revenue impact: $12,000 in delayed/denied services

Month 3:

 

• • Patients starting to complain about PA delays

• • 2 negative Google reviews mentioning “insurance hassles”

• • You’re considering dropping UHC/Cigna networks entirely

6-Month Reality:

 

• • PA denial rate: 18% (industry average without proper systems)

• • Staff burnout from PA administrative burden

• • Revenue lost: $45,000-$75,000

• • Patient satisfaction declining

This is preventable. But only if you act in the next 30 days.

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WHAT SUCCESS LOOKS LIKE

The 2026 PA Success Scenario

December 2025 (NOW): You implement WeBill PA service and update documentation standards.

January 2026: New rules take effect. You’re ready.

Week 1:

 

• • All PA requests include required outcome scores and functional goals

• • WeBill submits electronically where possible (faster processing)

• • Average turnaround: 7-9 days (payers meeting new standard for clients with complete documentation)

Week 2:

 

• • 95% PA approval rate (proper documentation prevents denials)

• • Staff time on PA: 3 hours weekly (down from 12) – WeBill handles submission and tracking

• • Zero patient appointment cancellations due to PA delays

Month 2:

 

• • 2 PA denials this month (out of 30 submitted)

• • WeBill appeals both with clinical justification

• • Both overturned within 14 days

Month 3:

 

• • Patients notice faster approvals

• • 1 positive Google review: “Dr. Smith’s office handles insurance stuff so smoothly!”

• • You’re focusing on patient care, not PA paperwork

6-Month Reality:

 

• • PA approval rate: 95% (vs. 82% industry average)

• • Staff morale improved (less administrative frustration)

• • Revenue protected: $200,000+ in services approved without delay

• • Patient satisfaction high

The difference between these scenarios? A $2-$5 investment per PA and 30 days of preparation.

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THE BOTTOM LINE

Prior authorization is the most hated administrative burden in healthcare. And it’s about to get more complicated.

The 2026 reforms promise relief: 72-hour urgent responses, 7-day standard responses, 80% real-time electronic approvals by 2027.

The reality: Most reforms are voluntary pledges with zero enforcement. Insurers made identical promises in 2018. Nothing changed.

What WILL change: CMS’s enforceable rules for Medicare Advantage/Medicaid (72-hour/7-day deadlines), and Medicare’s WISeR Model bringing PA to Traditional Medicare in 6 states.

Your choice:

 

1. 1. Do nothing and face 18%+ PA denial rates, 12+ hours weekly staff burden, $15,000+ annual revenue loss

1. 1. Implement systems now and achieve 95%+ approval rates, 3-hour weekly staff burden, protected revenue

The practices that thrive in 2026 will be those that:

 

• • Update documentation to meet stricter PA requirements (outcome scores, functional goals)

• • Implement PA tracking systems (threshold alerts, submission reminders)

• • Partner with PA specialists (WeBill) for complex, high-value authorizations

Prior authorization isn’t going away. But losing revenue to PA denials is 100% preventable.

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GET YOUR FREE PA BURDEN ASSESSMENT

Want to know exactly how much prior authorization is costing your practice?

We’ll analyze:

 

• • Your last 90 days of PA requests (volume, approval rate, turnaround time)

• • Staff time burden (hours weekly + cost)

• • Denial rate and common rejection reasons

• • Potential savings with WeBill PA service

No cost. No obligation. Just intelligence on where you’re losing time and money.

👉 Schedule your assessment: [webillhealth.com/pa-assessment]

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WeBill Prior Authorization Service:

Pricing:

 

• • Simple PA: $2 per authorization

• • Moderate PA: $3 per authorization

• • Complex PA: $5 per authorization

What’s Included:

 

• • Pre-submission documentation review

• • Payer-specific submission (portal, fax, phone)

• • Tracking and follow-up

• • Denial management and appeals

• • Real-time status alerts

The Guarantee: If our documentation review misses a required element and your PA is denied for incompleteness, we handle the resubmission at no charge.

📞 (425) 818-9351 📧 pa@webillhealth.com

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NEXT ISSUE PREVIEW

Coming Next: “AI in Medical Billing: Why Payers Use It Against You (And How to Fight Back with Your Own)”

We’ll expose:

 

• • How payer AI auto-denies claims in milliseconds based on cost thresholds

• • The 49% denial rate some insurance plans achieve with AI screening

• • Why 61% of physicians believe AI is increasing denials (AMA data)

• • How to use AI for pre-submission validation (beat them at their own game)

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Practice Vitals by WeBill Defending revenue for independent healthcare practices

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