Single-practice PA problems are workflow problems. Multi-site health system PA problems are coordination problems. The distinction matters because the solutions are different — and because most PA automation tools are designed for the former while health system RCM directors are dealing with the latter.
This post is about what actually happens to a revenue cycle team when a growing health system crosses the threshold of 200 or more PA requests per week across multiple departments and sites. We're drawing on conversations with RCM directors at mid-size systems — not naming any specific organizations — plus our own understanding of how PA volume scales with organizational complexity. The patterns are consistent enough to be instructive even if the exact numbers vary.
The Volume Threshold Where Things Break
A single specialty practice processing 30–40 PAs per week can function — imperfectly but manageably — with 1.5 to 2 FTE PA coordinators and a defined submission process. When a growing health system aggregates multiple specialty departments, the arithmetic changes faster than most finance teams expect.
A system with 5 specialty departments averaging 40 PAs per week each is processing 200 PAs weekly system-wide. At the same per-request time investment we described in earlier posts — roughly 2 hours of staff time per request end-to-end — that's 400 staff hours per week, or 10 FTE equivalents assuming 40-hour weeks. That's before accounting for the coordination overhead that multi-site structures introduce on top of the per-request workload.
The coordination overhead is where health systems diverge from practice-level math. In a single practice, the PA coordinator knows every physician's documentation style, has a working relationship with the billing team, and can walk down the hall to get a missing record. In a 5-site system, coordinators may be managing PAs across departments where they've never met the clinical staff, where documentation conventions differ, and where records come through different EHR instances or from different ambulatory EMR platforms.
How Payer Mix Complexity Multiplies the Problem
Health systems serving broader geographic and demographic footprints typically have more complex payer mixes than single-specialty practices. Where a private orthopedic group might have 60–70% of its PA volume concentrated in 4–6 commercial payers, a multi-site system's PA volume might span 12–18 active payers including multiple Medicare Advantage plan variants, state Medicaid managed care organizations, and commercial plans with county-level or employer-group-specific benefit structures.
Each additional payer adds configuration complexity: different portal credentials, different clinical criteria for common procedure categories, different turnaround time behavior, different denial reason taxonomy, and different peer-to-peer call scheduling processes. A PA coordinator who handles 10 payers well and is then asked to manage 18 is not twice as burdened — they're operating with a significantly higher cognitive load because each payer has idiosyncratic quirks that require accumulated institutional knowledge to navigate efficiently.
Medicare Advantage plan proliferation has made this worse. In major metropolitan markets, a health system may be dealing with 6–8 distinct MA plans from major national payers, each with different formularies and PA requirement lists for the same CPT codes. A coordinator who knows exactly which procedures require PA under UnitedHealthcare's Community Plan MA variant versus their Group MA variant is carrying knowledge that took months to build and disappears when they leave.
The Staffing and Knowledge Retention Problem
RCM teams at growing health systems consistently report PA coordinator turnover as one of their highest-impact operational risks. The base pay for PA coordinators in metropolitan markets runs $19–$26/hour; experienced coordinators who've built payer-specific institutional knowledge are chronically recruited by other systems and payers. Training replacement coordinators to productivity takes 3–6 months.
This creates a structural knowledge retention problem that compounds with volume. A system processing 200 PAs per week with 8 coordinators has knowledge distributed across those 8 individuals in ways that aren't documented or transferable. When two coordinators leave in the same quarter — not unusual in a high-churn labor market — the system loses knowledge faster than it can be rebuilt, and denial rates spike as newer staff work through the learning curve.
The RCM directors we've talked with who have the most stable PA operations are the ones who've done the most work to codify payer-specific knowledge into written protocols and checklists. That codification work is valuable but fragile — protocols go stale as payer criteria change, and keeping them current requires dedicated effort that rarely gets prioritized against immediate queue management.
Cross-Departmental Standardization: What It Actually Requires
When health system RCM leadership decides to standardize PA workflows across departments, they run into a problem that's different from what single-practice administrators face: specialty-specific variation in what a PA-supporting clinical note needs to contain.
An orthopedic PA for CPT 27447 requires documented failure of conservative management, functional limitation scores (often WOMAC or Oxford Knee Score), and imaging evidence of joint space narrowing. A cardiology PA for CPT 93306 (echocardiography) requires clinical indications and relevant history of cardiac symptoms. A neurology PA for CPT 95910 (nerve conduction study) requires documented clinical indications and relevant symptom history. These aren't overlapping requirements — they're specialty-specific documentation standards that reflect each payer's medical necessity criteria for each procedure category.
Standardizing the submission process is achievable. Standardizing the upstream clinical documentation requirements across specialties requires either: (a) department-by-department documentation standards built and maintained by clinical staff with specialty knowledge, or (b) tooling that connects payer criteria to documentation requirements at the point of care so that the note contains what the PA needs regardless of whether the coordinator knows to ask for it.
Most health systems are attempting option (a). It works imperfectly and degrades over time as criteria change. Option (b) is what clinical documentation tools connected to PA workflows are designed to enable — the payer criteria inform what the note should capture, rather than requiring the coordinator to reconstruct what's missing after the fact.
What the Revenue Impact Looks Like at Scale
At 200 PAs per week with a 25% first-submission denial rate, a health system is managing 50 denials per week. If 30% of those are ultimately abandoned — procedures that don't happen or revenue that's written off rather than appealed — that's 15 procedures per week with no associated revenue. For procedures averaging $4,000–$6,000 in reimbursement across a mixed specialty portfolio, the weekly revenue at risk from abandoned PA cases is $60,000–$90,000. Annually, that's $3M–$4.7M.
We're not saying every health system at 200 weekly PAs is losing this amount — it depends heavily on denial rates, procedure mix, and how aggressively the appeals process is managed. What we're saying is that the magnitude of the revenue risk at this volume justifies significant investment in PA process improvement. The ROI math is even more compelling at health system scale than at single-practice scale.
The appeal backlog is the other significant cost at scale. Managing 20 open appeals per week — each requiring 90–120 minutes of combined coordinator and physician time — is 1,800–2,400 minutes of RCM staff and physician time weekly, or 30–40 hours. At health system staffing rates, that's $750–$1,100 in direct labor per week on appeal management alone, before factoring in physician time at a cost-per-minute rate well above coordinator rates.
What a Health System Needs That a Practice Tool Doesn't Provide
Single-practice PA tools are designed around a coordinator who knows their practice's context and manages a single queue. Health system PA operations need several additional capabilities that those tools don't address.
Cross-department visibility: the ability to see PA queue status, denial rates, and turnaround times across departments in aggregate, not just within one department's tool instance. RCM directors need to identify which departments are outliers — whether in denial rate, time-to-submission, or appeal success rate — to focus process improvement effort where it has the most impact.
Payer performance tracking: the ability to measure actual payer decision turnaround against contracted and regulatory timelines across all active payers, flagging chronic slow payers for escalation. At single-practice scale, this is informal. At 200 weekly PAs across 15 payers, systematic tracking is required to manage payer relationships effectively.
Documentation standards management: the ability to update payer criteria and documentation requirements centrally and have those updates propagate to the clinical documentation tooling across all departments, rather than requiring manual protocol updates site-by-site.
We're still an early-stage company and we're direct about the fact that health system scale is not where we're focused first. Our initial work is in specialty practices where the documentation-to-PA workflow connection is clearest and the coordination layer is simpler. But the health system problem is an extension of the same root cause — clinical documentation quality at the encounter doesn't consistently meet PA criteria — and the structural fix is the same at any volume.
The Standardization Opportunity
The health systems that have made the most progress on PA efficiency at scale have one thing in common: they've invested in making PA criteria visible to clinical staff at the point of documentation, not only to coordinators at the point of submission. When a physician generating a note for a procedure that will require PA is aware — through documentation templates, prompts, or structured note fields — of what the payer will need to see, the note is more likely to contain it. When that awareness isn't built into the clinical workflow, the coordinator's job is remediation after the fact, at a cost in time and denial rate that scales linearly with volume.
The 200-PA-per-week health system that solves this upstream documentation problem doesn't need 10 FTE of coordinator work — it needs coordinators doing review and submission rather than gathering and drafting. The headcount math improves, the denial rate improves, and the knowledge retention problem becomes less acute because the knowledge is embedded in the tool rather than distributed across individual staff.