Prior Authorization VisibilityStop Finding SLA Breaches in Last Month's Report
CMS now requires public reporting of PA decision turnaround times, denial rates, and appeal overturn rates at the case level. With 80.7% of appeals overturning denials, that transparency is about to expose operational failures. Can your team produce that report today? If it takes a 3-week spreadsheet, Operon can help.
Built for health plans and the clinical operations teams running them.
The Problem
SLA breaches discovered too late
PA cases cross 10+ stages, and failures show up in monthly reports weeks late. By the time you see a breach, the damage is done - the case is already non-compliant, and the member experience is already impacted.
Rework loops are invisible cost drivers
Cases loop 2-3x through the same stages before reaching a decision. Each loop adds days and cost, but nobody tracks how many loops a case takes or which stages generate the most rework.
CMS compliance is now non-negotiable
CMS-0057 requires 72-hour expedited and 7-day standard PA decision timelines, with public reporting of denial rates, approval rates, and appeal overturn rates. Here's the number that should keep you up at night: 80.7% of appeals overturn denials. That stat is about to become public. Plans with high denial rates and high overturn rates face Stars penalties, enrollment loss, and enforcement risk simultaneously.
Why This Can't Wait
CMS-0057: PA transparency rules now in effect with public reporting
72-hour expedited and 7-day standard decision reporting required at the case level. Denial rates, approval rates, and appeal overturn rates will be publicly reported. First mandatory PA metrics report due March 31, 2026. Plans can no longer hide behind aggregate numbers.
110+ state bills: 18+ states passed PA reform since January 2025
Multiple states now mandate decision timeframes shorter than CMS minimums. Indiana requires 24 hours urgent, Iowa requires 48 hours urgent.
AI transparency laws effective January 1, 2026
Texas and California require disclosure when AI contributes to adverse PA determinations. Plans need case-level documentation that AI is not solely driving denials.
2027 deadline: 80% of PA requests must be answered real-time via API
Most plans still store medical policies in static PDFs and Word docs. WEDI found that digitizing PA policies was the #1 implementation challenge. The gap between where plans are and where CMS requires them to be is measured in years, not months.
What Operon Shows You
Operon connects to your PA case management systems and builds a live operational map of every case in flight. Within 2-4 weeks, your team sees exactly where cases stall, which SLAs are at risk, and where rework concentrates - from actual case-level data, updated continuously.
Friction Matrix
The monthly report told you a breach happened. The Friction Matrix shows you where cases slow down right now - which stages accumulate the most dwell time, which ones generate repeat touches, and where your team should intervene today.
SLA Exposure Profile
Every PA case has an SLA clock. This view shows how much budget each case has burned, which stages are consuming it fastest, and which cases will breach if nothing changes - so your team acts while there's still time, not three weeks later.
Risk AI
Machine learning scores every active PA case by breach probability. Instead of reviewing cases one by one, your team sees a ranked list of the cases most likely to miss SLA - and can intervene before they become CMS compliance failures.
Loop Atlas
Cases that loop 2-3x through the same stages cost days and dollars that nobody tracks. Loop Atlas visualizes every rework cycle, counts the touches, and calculates the cost - so you know exactly which stages to fix to stop the looping.
How It Works
Connect
Lightweight integrations with 3-5 data sources. Minimal IT involvement - read-only access to your PA workflow systems.
See
Dashboards live in 2-4 weeks. SLA tracking, bottleneck detection, rework quantification, and risk scoring from day one.
Act
Intervene on at-risk cases before they breach. Reallocate resources to bottleneck stages. Report compliance metrics with confidence.
From ThinkSpace
CMS-0057-F Prior Authorization API testing with Operon
Let's See If We Can Help
No pitch deck. No pressure. Just a conversation about what you're trying to solve and whether we're a fit.
Good fit if you're:
- Running clinical workflows and can't see where cases stall or why
- Managing multiple vendors and teams with no unified performance view
- Trying to answer 'what does a case cost?' without a 3-week spreadsheet
- Running AI in production but can't prove the ROI
Book a Call
- 30 minutes with our founding team
- Discovery, not a demo
- Honest assessment of fit
Or email us at sales@operon.cloud