Healthcare Policy Intelligence for Denial Risk, Prior Auth & CMS Compliance
"Policy changes are public. is not."
Use PAULA's Risk Assessment to see where payer policy, denial risk, revenue exposure, and operational friction may be affecting your facility — no PHI required.
Same policy. Different desk.
Every PAULA briefing ships in the lens you actually need — revenue exposure for finance, defensibility for clinical governance, denial scenarios and P2P scripts for UM.
Hospital CFOs & Revenue Cycle Executives
- Modeled revenue-at-risk range with stated baseline assumptions
- Payer-mix impact map (MA, Medicaid MCO, CHIP, commercial)
- Denial-rate trajectory and the cohorts that move first
Chief Medical Officers & Clinical Governance Leaders
- Clinical governance obligations mapped to each rule
- Human-review attestation language your reviewers can sign
- Predictive DSI disclosure and inventory requirements
Physician Advisors & Utilization Management Directors
- Medical necessity framing for the affected cohort
- Concrete denial scenarios with payer rationale patterns
- Documentation vulnerabilities ranked by frequency
NEWEST BRIEFINGS
VIEW ALL →Built by a Physician.
PAULA was created by a board-certified internist who sat on both sides of the utilization review table — and decided the conflict of interest was a problem worth solving.
PAULA has zero payer affiliation. Zero. Built by a physician who sat on both sides of the utilization review process.
Policy summaries are everywhere.
Most public sources can tell you what changed. PAULA tells you what it means — for admissions, denials, documentation, revenue exposure, compliance posture, and UM workflow.
Structured extraction
Policy updates are decomposed into discrete logic fields — not loose narrative notes.
Denial-risk mapping
Rules organized around documentation vulnerabilities, payer arguments, and escalation triggers.
Role-based outputs
The same policy, translated differently for clinical, operational, financial, compliance, and underwriting leaders.
AI POLICY & REIMBURSEMENT TRACKER
Free tier exposes the metadata. The interpretation — logic cards, denial scenarios, revenue impact, role-based briefs — sits behind clearance.
- Policy title
- CMS / payer policy update
- Agency
- CMS / payer / state
- Effective date
- Visible
- Source URL
- Visible
- Category
- Prior Authorization · AI Disclosure
One policy. Multiple stakeholders.
The persona lens describes how PAULA reframes the same policy. The actual findings remain gated.
Physician Advisor Lens
Denial vulnerabilities, documentation gaps, peer-to-peer talking points, and medical necessity framing.
UM Director Lens
Authorization timing, process changes, staff training needs, escalation triggers, case management impact.
CFO / Revenue Lens
Revenue exposure, denial concentration risk, payer impact modeling, operational cost signals.
Healthcare and Industry Lens
Regulatory obligations, audit readiness, policy revision requirements, governance implications, and documentation expectations.
Underwriter & Risk Executive Lens
Emerging liability signals, documentation exposure mapping, AI governance risk, claims trend forecasting, and underwriting control recommendations.
The intelligence model is visible.
Free users see that PAULA found structured intelligence for every record. They cannot open the work product without clearance.
Three tiers.
The free tier is intentionally lean. It proves the corpus exists without giving away interpretation.
Public Timeline
- Browse timeline
- Card titles, agency, effective date
- Category & source URL
- Request Enterprise Watchlist
Intelligence Access
- Short summaries & logic cards
- Decision lenses & full analysis
- Revenue calculator
- Payer impact matrix
- Denial scenarios & PDF export
One-Time Briefings
- Sold individually via Stripe
- Full Intelligence Brief
- CFO / CMO / UM lenses
- Subscriptions coming soon
Not generic PDFs.
PAULA transforms policy movement into role-specific operational intelligence for healthcare leaders. Every briefing answers four critical questions and ships in the lens you actually need.
What Changed?
A concise breakdown of the policy update, reimbursement change, payer rule revision, regulatory action, or utilization management development.
When Does It Take Effect?
Key implementation dates, comment deadlines, enforcement triggers, and the operational windows your teams must hit.
Who Is Affected?
Payers, service lines, settings of care, and the leaders inside your organization who own the response.
What Should You Do?
Concrete operational moves — documentation levers, escalation pathways, contracting posture, and CLIP guardrails — sequenced by urgency.
Payer Prior-Auth APIs Go Live — Decision Rationale Becomes Discoverable
MA, Medicaid, CHIP, and FFM QHPs must run a PA API, return specific denial rationale, and meet 72hr/7d response windows. The rationale field becomes the appeal anchor.
MA Plans Must Now Justify Their UM Criteria — And You Can Demand to See Them
CY2026 MA Final Rule requires UM Committee review, public posting of internal criteria, and annual health-equity analysis of prior auth. Three new documentary demands per appeal.
EHR-Embedded Predictive AI Now Carries Source-Attribute Disclosure Obligations
Every predictive DSI in a certified EHR carries source-attribute and intervention risk management obligations — discoverable in payer disputes, OCR §1557, and state AG inquiries.
California's AI-in-UM Model Is Spreading — Texas and New York Are Next
Texas and New York are advancing physician-final-decision bills patterned on CA SB 1120. One appeal frame scales across emerging statutes.
New State AI-in-UM Law Reshapes Payer Obligations in Your Market
California SB 1120 (Physicians Make Decisions Act) prohibits AI-only medical necessity denials by Knox-Keene plans and disability insurers. A licensed physician must make the final call, based on individualized clinical circumstances — not group datasets.
New AI Service Pathway Creates Reimbursement Opportunity — and Audit Exposure
FY 2027 IPPS Proposed Rule would repeal the alternative NTAP pathway for FDA Breakthrough Device-designated AI products beginning FY 2028. All AI devices would need to meet the full three-criteria standard — newness, cost adequacy, and substantial clinical improvement.
AI-Driven Denials Now Require Defensible Human-Review Documentation
CMS-4201-F prohibits MA plans from using algorithms as the sole basis for adverse coverage decisions. ONC HTI-1 and HHS OCR §1557 expand legal exposure of unaudited AI in UM. Human-review attestation is the controlling defense.
CMS IPO Change Creates Immediate Admission Denial Risk
CY 2026 OPPS final rule phases out 285 procedures from the Inpatient-Only list, resetting site-of-service denial logic. Two-Midnight documentation becomes the controlling defense for every Table 119 admission.
Federal Enforcement Signals Expanding Payer-Behavior Scrutiny
Senate PSI 'Refusal of Recovery' report documents UHC, Humana, and CVS/Aetna MA post-acute denial patterns tied to nH Predict and Post-Acute Analytics. CLIP-grade appeal record-building required for every AI-assisted denial.
Two-Midnight Enforcement Will Drive Observation Downgrades
MAC TPE has replaced BFCC-QIO review for short-stay inpatient admissions. PA, CFO, and Compliance lenses with denial scenarios and PIM Exhibit 48 citations.
WISeR Prior Auth Tightening Across Traditional Medicare
CMS's WISeR pilot extends AI-assisted prior authorization into Traditional Medicare for targeted services. UM, denial-risk, and documentation framing for affected service lines.
Analysis tailored to your role.
Select a briefing to preview the intelligence. Choose a lens to receive analysis tailored to your role — or unlock the Full Executive Brief to view the complete PAULA intelligence package.
CFO Lens
Revenue exposure, payer-mix impact, denial-rate trajectory, contracting leverage, and executive action points for finance leadership.
CMO Lens
Clinical governance, defensibility, physician leadership posture, utilization management implications, and peer-to-peer readiness.
UM / Physician Advisor Lens
Medical necessity framing, denial scenarios, documentation vulnerabilities, escalation pathways, and P2P scripts.
Healthcare and Industry Lens
Regulatory obligations, audit readiness, policy revision requirements, governance implications, and documentation expectations.
Underwriter & Risk Executive Lens
Emerging liability signals, documentation exposure mapping, AI governance risk, claims trend forecasting, and underwriting control recommendations.
Request an
For hospitals, health systems, advisory firms, and compliance teams that need custom monitoring by payer, service line, state, and facility type.
- Payer-specific policy tracking
- Service-line denial-risk monitoring
- State & federal policy variability
- Role-based executive reporting
- Custom briefing workflows
- Dedicated review cadence
Generate your facility-specific PAULA Risk Brief.
Use PAULA's Risk Assessment to see where payer policy, denial risk, revenue exposure, and operational friction may be affecting your facility — no PHI required.