72% straight-through prior authorizations at an 11-hospital system — agentic RCM
An 11-hospital IDN was losing scheduled procedures to prior-auth delays and paying overtime to clear a growing backlog. pronix.ai deployed a multi-agent prior-auth system that read the order, pulled clinical evidence, matched payer policy and submitted through Availity or payer portals — 72% of authorizations completed straight-through with turnaround compressed from six days to under 24 hours.
- Client
- Integrated delivery network, 11 hospitals and 240 clinics
- Industry
- Healthcare Providers
- Platform
- Epic · Kore.ai Agent Platform · Azure OpenAI · Availity
*Representative outcome; results vary by client, scope and platform configuration.
The challenge
Roughly 38% of procedures required prior authorization, and each one consumed 22 minutes of coordinator time. Denials for missing clinical evidence were rising, elective volume was being pushed out, and payer policies shifted faster than the team could re-train staff.
Our approach
Payer-policy knowledge graph
Ingested payer medical policies, LCD/NCD rules and plan-specific criteria into a governed knowledge graph refreshed nightly — every auth decision cited the exact policy paragraph and version.
Clinical evidence agent
An Epic-integrated agent pulled the relevant note, imaging report, labs and prior treatment history, redacted non-required PHI and assembled a payer-ready packet in under 90 seconds.
Submission & follow-up orchestration
Multi-channel submission through Availity APIs, payer portals and fax fallback — with a status agent that polled and re-worked pends automatically inside the payer's response window.
Human review on exceptions only
Coordinators reviewed only the ~28% of cases with missing evidence, medical-necessity nuance or peer-to-peer triggers — pre-drafted with recommended next step.
“Prior auth stopped being the reason we lost a case on the schedule. Coordinators now spend their time on peer-to-peers, not paperwork.”
Illustrative case study. Scenarios, metrics, quotes and client details are representative composites based on Pronix engagements and industry benchmarks unless a named client is shown with written consent. Outcomes vary by client, scope, data quality and platform configuration. Nothing on this page is a guarantee, warranty or professional advice. See our Terms of Use for the full disclaimer.
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