Technology Council
Operator-side writing on the administrative machinery behind specialty care prior authorization, Medicaid policy and referral intake.
The federal autism tool kit reads like a checklist for ABA billing: authorization matching inside the claim path, delivered hours reconciled against authorized hours, session notes a query can actually read, credentials tracked as live state, and the outlier queries CMS has already published.
Practices far from Indianapolis kept asking whether Indiana’s overhaul would reach them. It already had — as a data-architecture problem, before it ever showed up as a policy one.
Every ABA practice tracks new patient volume. Almost none tracks what share of referrals reach a completed first visit — which is exactly where revenue disappears without setting off a single alarm.
Therapy owners assumed traditional Medicare would never require prior authorization. That assumption held for about 30 years and stopped being true on January 1, 2026, when CMS launched the WISeR model.
Fewer enrolled patients, higher cost per enrollee, and an increasingly adversarial claims process between providers and their revenue — with five priorities for the leaders closing the gap.
The administrative weight lands hardest on specialty clinics: smaller teams, tighter margins, and procedures that demand more documentation and more prior authorizations than primary care.
Six months of implementation, dozens of trainings, then the call: “We’re turning it off.” Most healthcare AI does not fail because the technology is flawed — it fails because the implementation was never designed for the real world.
Forbes Technology Council is an invitation-only community for senior technology executives. Articles are published on Forbes.com under Forbes' editorial process.
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