PAULA · PAYER FRICTION PROFILE™ · CFO BRIEF

Payer Friction Index — CFO Brief

Artifact 8.6.17.v3 · 28 payer × line-of-business records across 19 parent insurers · reporting year 2025 (CMS-0057-F self-reported), sourced from the KFF analysis published 2026-08-13. Prepared for hospital CFO, revenue-cycle, and payer-relations leadership.

WHAT THIS ANSWERS

Where denial pressure is concentrated by payer and line of business, and whether the recoverable response is appeals throughput or upstream prevention — before the next contracting cycle or staffing plan.

01 — THE SCORE

PFI Core = 100 × clamp(standard denial rate / 0.30, 0, 1)

It measures one thing: standard prior-authorization denial burden, normalized against a fixed 30% ceiling. Appeal overturn, response time, and policy volatility are deliberately excluded from the score and reported separately. Because the ceiling is fixed rather than pool-relative, a score of 60 means the same denial rate in every line of business and every reporting year within this regime. Adding payers to the set does not move any existing score.

02 — FOUR OPERATING POSTURES

Records are classified on two axes — standard denial rate and appeal overturn rate — against reference cut-points drawn from the 2025 cohort itself (0.13 denial, 0.43 overturn). These are descriptive splits of the observed pool, not standards of acceptability.

Fight
High denial / high reversibility · n = 8

Appeal capacity and appeal-package quality. Recoverable volume is real.

Prevent
High denial / low reversibility · n = 7

Documentation, medical-necessity capture, front-end authorization accuracy. Appeals are a poor use of staff time.

Monitor / Challenge
Low denial / high reversibility · n = 6

Selective case-by-case challenge rather than absorbing denials. No dedicated program needed.

Lower observed friction
Low denial / low reversibility · n = 6

Monitor for change. Do not allocate dedicated capacity on this measured slice.

One record — L.A. Care Health Plan (Medicaid managed care, CA) — is unclassified because the source reports no appeal overturn rate for it. It carries a PFI Core score of 6.67 and no posture.

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Source: KFF, Prior Authorization Metrics Provide New Insights Into Insurer Practices, But Gaps Remain (Aug 13, 2026). 2025 CMS-0057-F self-reported payer data.

FIXED-SCOPE ENGAGEMENT · $2,500

Map your institution's Payer Friction Profile.

This brief answers the national question. The one that drives your staffing plan and your next contracting cycle is local: which of your payers, at which line of business, is a Fight, a Prevent, or a Monitor.

PAULA overlays your contracted payer mix against this index — payer by payer, product by product — and returns a quadrant-classified profile with three named outputs: where incremental appeal capacity returns the most, where documentation and front-end authorization accuracy returns more than appeals ever will, and what to bring to the table at the payer × line-of-business grain.

  • Your payer × line-of-business friction profile, scored against the 2025 cohort
  • Fight vs. Prevent posture assignment for your top payers — appeals or upstream prevention
  • Payer-level asks for your next contracting cycle, at the product grain the data supports
  • Fixed scope, fixed price: $2,500. One-time engagement — no ongoing commitment.
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