A five-year-old’s rare-disease journey exposes an uncomfortable truth about healthcare: the problem we see downstream often began much earlier.
“When practices cannot sustain themselves, patients have
a harder time finding and keeping the physicians they need.” — Willie
Underwood III, MD, MSc, MPH, AMA President, September 14, 2026
The Five-Year-Old Who Exposed a Revenue-Cycle Problem
Sophia was five years old.
She loved stickers.
Painting.
Bluey.
SpongeBob.
And, apparently, decorating anything within reach with
enough stickers to make an adult wonder whether adhesive technology had finally
gone too far.
But for almost half her life, Sophia had also been dealing
with something much more serious.
Three years ago, she developed sudden, rapid weight gain.
Her parents, Kelly and Joseph, initially thought it might be
related to the excitement and stress of becoming big siblings to twins.
They took her to her pediatrician in Western New York.
She was referred to an endocrinologist and a nutritionist.
At first, they were told everything seemed fine.
Then routine bloodwork showed elevated sodium levels.
Then came a seizure.
A week-long hospitalization followed.
Further testing showed that Sophia's oxygen levels were
dropping.
Doctors recommended a sleep study.
Her parents began researching.
And eventually they recognized a disturbing pattern.
Sophia's symptoms matched ROHHAD syndrome, an
extremely rare and life-threatening condition.
Her parents researched where to go.
They found Dr. Leslie Benson, co-director of Boston
Children's Neuroimmunology Center and a leading expert in ROHHAD.
They traveled from Western New York to Boston.
And there, something changed.
Not because healthcare suddenly became simple.
It didn't.
Sophia still needed extensive testing, including a full-body
MRI, more extensive sleep studies and a lumbar puncture. She required ongoing
treatment and continued specialist care.
But her father, Joseph, described the experience this way:
“It was such a relief to arrive in Boston and be told
that not only had they treated kids with ROHHAD before but that they also had a
plan.”
That sentence stopped me.
They had a plan.
Not:
“They had another portal.”
Not:
“They had another dashboard.”
Not:
“They had another spreadsheet.”
A plan.
Because someone finally connected the pieces.
And that is where Sophia's story becomes surprisingly
relevant to medical billing.
Your Denial May Not Be the Problem
Here is the contrarian idea:
The claim is often where the problem becomes visible—not
where the problem began.
Yet much of revenue-cycle management is organized around
what happens after the problem appears.
The claim is denied.
Someone investigates.
Someone calls.
Someone checks the payer portal.
Someone searches the chart.
Someone sends an email.
Someone corrects something.
Someone resubmits.
Someone waits.
Someone follows up.
Someone appeals.
Eventually, money arrives.
Everyone breathes.
Then three weeks later:
Congratulations. You're doing it again.
This is one of healthcare's strangest operational habits.
We become extraordinarily good at repairing problems that we
never bothered to prevent.
The Billing Team Might Be the Victim
We often talk about revenue-cycle problems as if the billing
department owns them.
That's convenient.
It's also frequently incomplete.
Imagine this:
A claim is denied because authorization was missing.
The natural reaction is:
“Billing needs to fix it.”
But let's walk backward.
Who scheduled the patient?
Who verified eligibility?
Who identified the authorization requirement?
Who requested authorization?
Who documented the approval?
Who knew the service had changed?
Who communicated the change?
Who captured the clinical information?
Who confirmed that the information required for the claim
actually existed?
Suddenly, “the billing problem” has become a workflow
problem.
And workflow problems have a nasty habit of crossing
departmental boundaries.
Healthcare Has a Data Problem Disguised as a Billing
Problem
Healthcare has no shortage of information.
We have EHRs.
Practice-management systems.
Clearinghouses.
Payer portals.
Authorization platforms.
Patient portals.
Analytics.
Automation.
AI.
And enough logins to qualify some employees for a second
career in password management.
Yet information can still fail to reach the person who needs
it.
That's the paradox.
Digital does not mean connected.
A fax converted into a PDF is still a fax.
A spreadsheet emailed between departments is still a
handoff.
A portal that requires someone to remember to check it is
still a manual workflow.
And AI sitting on top of fragmented information may simply
become a very sophisticated way to misunderstand the same problem faster.
The Revenue Cycle Doesn't Start With the Claim
This is where I think the traditional mental model needs to
change.
Revenue cycle is often perceived as:
Claim → Denial → Appeal → Payment
But the actual chain begins much earlier:
Patient registration
↓
Scheduling
↓
Eligibility
↓
Authorization
↓
Encounter
↓
Documentation
↓
Coding
↓
Charge capture
↓
Claim submission
↓
Payer processing
↓
Payment
↓
Reconciliation
The claim is not the beginning.
It is a downstream event.
By the time a claim is denied, several opportunities to
prevent that denial may already have passed.
The Denial Is a Lagging Indicator
This distinction matters.
A denial tells you something happened.
It does not necessarily tell you where the problem
originated.
Think of a dashboard light in your car.
When it comes on, you don't congratulate yourself for having
successfully identified a light.
You ask:
What caused it?
Healthcare should approach denials the same way.
Don't just ask:
“Why was this claim denied?”
Ask:
“What allowed this problem to survive every checkpoint
before the claim?”
That is a much more interesting question.
And potentially a much more valuable one.
Here's the Really Uncomfortable Part
Your organization may be measuring the wrong success.
Suppose your billing team catches 500 errors before
submission.
Great.
But what if those errors could have been prevented upstream?
The claim may still go out clean.
The denial rate may look fantastic.
The A/R may look healthy.
But your employees are spending hundreds of hours quietly
cleaning up problems before they become visible.
You haven't eliminated the friction.
You've hidden it.
This is why clean claims alone do not tell the entire story.
A clean claim can be produced by a clean workflow.
Or by exhausted employees who manually scrub every problem
before submission.
Those are not the same thing.
HFMA Has a Warning Hidden in Plain Sight
A 2026 HFMA Clean Claims study found that only 28% of
survey respondents had fully automated claims submission, while 58%
relied on a hybrid model of automation and manual intervention.
The study also identified front-end claim scrubbers as
highly effective for improving claim accuracy and accelerating payment, while
noting that changing payer requirements can undermine the effectiveness of
static edits.
That tells us something important.
Automation exists.
But humans remain deeply involved.
The question is not whether humans should disappear.
They shouldn't.
The better question is:
What are humans spending their time doing?
Judgment?
Exception handling?
Patient communication?
Clinical reasoning?
Or repeatedly correcting predictable information problems?
The Patient Should Not Become the Middleware
This may be the most ridiculous part of fragmented
healthcare.
Two organizations have information.
Their systems don't communicate properly.
So the patient gets asked to provide the information again.
Then again.
And sometimes again.
The patient becomes the integration layer.
Think about that.
The healthcare system has invested billions in technology,
yet the human being receiving care sometimes becomes the API.
That is not sophisticated healthcare infrastructure.
That's a workaround with a pulse.
And Physicians Become the Backup System
The same thing happens internally.
The scheduler can't find something.
The biller needs clarification.
The authorization team needs documentation.
The payer needs information.
The physician gets a message.
Another message.
Another “quick question.”
Another inbox notification.
Another task.
Eventually, the physician becomes the human middleware
connecting systems that were supposed to connect themselves.
And then we wonder why physicians feel buried in
administrative work.
AMA's Warning Is Bigger Than Payment
That is why the AMA's latest warning about physician payment
caught my attention.
On September 14, 2026, AMA President Willie Underwood
III, MD, MSc, MPH, said that what began as a physician payment challenge
had become a patient-access problem. The AMA argued that when practices cannot
sustain themselves, patients have greater difficulty finding and keeping
physicians.
That statement is important even if you set aside the
broader policy debate.
Because it highlights a basic operational truth:
Financial friction eventually becomes healthcare
friction.
When revenue is delayed, practices compensate.
When administrative work expands, practices compensate.
When staff spend hours on rework, practices compensate.
When physicians are pulled into billing problems, practices
compensate.
Somebody always pays for broken workflow.
Sometimes it's the practice.
Sometimes it's the employee.
Sometimes it's the physician.
Sometimes it's the patient.
Usually, it's some combination.
Prior Authorization Is a Perfect Example
Prior authorization is one of the clearest demonstrations of
what happens when information and workflow fail to connect.
CMS estimates that requesting prior authorization costs
providers $20–$50 per hour and consumes an average of 13 hours per
week per provider, or roughly 700 hours annually.
CMS is now pushing toward electronic prior authorization,
with certain affected health plans required to implement and maintain APIs
beginning January 1, 2027.
That is a major shift.
But here's the part worth watching:
Electronic does not automatically mean intelligent.
If you digitize a fragmented process without redesigning the
process, you may simply replace:
Fax → Portal
with:
API → Different Portal
Congratulations.
The fax machine got promoted to software.
The Real Opportunity Isn't More Technology
This is where I differ from some of the healthcare
technology conversation.
I don't think healthcare necessarily needs another shiny
system.
It needs better system design.
Before buying another tool, ask:
Where does the problem begin?
Not:
Where does the problem become visible?
Those are different questions.
A denial may appear in billing.
But its root cause could be:
- registration
- eligibility
- authorization
- documentation
- coding
- scheduling
- payer-rule
changes
- communication
- system
integration
- unclear
ownership
If you build your solution around the location where the
problem appears, you may miss where it began.
Stop Celebrating Firefighters
Healthcare loves heroes.
The employee who stays late.
The biller who rescues a complicated claim.
The practice manager who calls the payer six times.
The physician who personally fixes the authorization.
The employee who remembers the weird payer rule nobody
documented.
We celebrate these people.
And we should appreciate them.
But here's the uncomfortable question:
Why does the organization need so many heroes?
A healthy system should not depend on extraordinary effort
to survive ordinary workflows.
If your best employee has become indispensable because they
know all the workarounds, you may not have built a great system.
You may have built a system that requires one person to
remember how broken it is.
The Most Expensive Employee May Be the One Doing Rework
This is not an argument against employees.
It's an argument for respecting their time.
Suppose an employee spends hours every week:
- looking
for missing information
- correcting
demographic data
- checking
authorization status
- calling
payers
- reconciling
mismatched information
- searching
through portals
- correcting
predictable claim errors
That labor is real.
But it may not create new value.
It is recovery work.
The strategic question becomes:
How much recovery work can we eliminate?
That is where technology becomes interesting.
Not because AI is fashionable.
Because unnecessary work is expensive.
AI Should Not Be the Hero of the Story
Here's another contrarian position:
“AI-powered” is not a strategy.
It is a description.
Maybe.
Sometimes it is marketing.
The question should be:
What does the AI actually prevent?
Does it identify missing information?
Does it detect inconsistencies?
Does it recognize patterns in recurring denials?
Does it surface authorization problems before service?
Does it route exceptions?
Does it reduce repetitive staff intervention?
Does it help the right person act at the right time?
If not, congratulations.
You may have purchased an AI-powered dashboard.
The dashboard will look fantastic.
Your staff will still be busy.
Machines Should Handle Patterns. Humans Should Handle
Exceptions.
That is the model I find more compelling.
If something happens thousands of times and follows
predictable rules, technology should help.
If something is unusual, ambiguous or clinically nuanced,
humans should be involved.
The goal is not:
Human vs. AI.
The goal is:
Human attention where human attention matters.
Imagine a system that quietly handles predictable validation
and routing while escalating the genuinely unusual cases.
The physician sees fewer interruptions.
The biller sees fewer repetitive tasks.
The practice manager sees fewer fires.
The patient experiences fewer administrative surprises.
That's a much better definition of automation.
What OnnX Is Trying to Rethink
This is the problem I am working on with OnnX.
The premise is simple:
Revenue problems often begin before the revenue cycle
looks like a revenue-cycle problem.
OnnX is being built around an upstream approach to
healthcare revenue operations.
That means paying attention to the information and workflow
leading into the claim—not simply what happens after a payer rejects it.
The focus includes areas such as:
Eligibility
Authorization
Clinical context
Documentation
Charge capture
Information consistency
Workflow handoffs
Exception management
The goal isn't to promise that every denial disappears.
That would be unrealistic.
Healthcare is too complicated for that.
The goal is more practical:
Find preventable friction earlier.
The Sophia Test
Here's a test I would apply to healthcare technology.
Imagine Sophia's care journey.
Her parents had information.
Different physicians had information.
Specialists had information.
Eventually, the right team connected those pieces.
The result wasn't that the case became simple.
The result was that the family finally had a coherent plan.
Now apply the same test to your revenue cycle.
Ask:
Does this technology connect the information needed to
make the next decision?
Or does it simply create another place to look?
That distinction is enormous.
The Five Questions Every Practice Should Ask
Before blaming billing, ask these five questions.
1. Where did the problem actually begin?
Not where it was discovered.
Where did it originate?
2. Who had the information first?
Was it registration?
Scheduling?
The clinical team?
Authorization?
The payer?
3. Why didn't the next person receive it?
Was the problem technical?
Procedural?
Human?
Organizational?
4. How many times have we fixed the same thing?
If the answer is “all the time,” stop calling it an isolated
mistake.
It's a process.
5. Can we detect it earlier?
That's the question that moves the conversation from
recovery to prevention.
A 30-Day Upstream Experiment
You don't need a multimillion-dollar transformation program.
Pick one service line.
One recurring problem.
One month.
Week 1: Follow the patient
Track 25 patient journeys from scheduling through payment.
Don't follow the organizational chart.
Follow the information.
Week 2: Find the friction
Look for:
Missing information
Incorrect information
Delayed information
Duplicate entry
Manual handoffs
Unclear ownership
Payer-rule changes
Documentation gaps
Week 3: Fix one upstream failure
Choose one.
Define:
Trigger → Owner → Action → Escalation → Resolution
Week 4: Measure recurrence
Track:
Denial frequency
Repeat denials
Staff touches
Authorization completion
Charge lag
Rework
Physician interruptions
The goal isn't to produce a beautiful report.
The goal is to discover whether one small upstream change
reduces downstream chaos.
Measure What Happens Before the Denial
This is where I would change the dashboard.
Don't only show:
Denial rate
Also show:
Eligibility accuracy
Authorization completion before service
Registration error rate
Documentation completeness
Charge lag
Manual intervention rate
Repeat-error rate
Time to identify an upstream issue
Those metrics tell you something different.
They tell you whether the system is becoming more
preventive.
A Warning About “Efficiency”
Efficiency can be deceptive.
Suppose your denial rate falls.
Great.
But staff hours increase.
Not so great.
Suppose A/R improves.
Great.
But physicians are spending more time answering billing
questions.
Not so great.
Suppose claims go out clean.
Great.
But employees are manually fixing thousands of errors before
submission.
Again, not exactly a victory parade.
Efficiency is not simply getting the right outcome.
It's getting the right outcome without unnecessary effort.
The Ethical Question
There is a human consequence to all of this.
Administrative friction doesn't remain administrative
forever.
It leaks into the patient experience.
It leaks into physician attention.
It leaks into employee burnout.
It leaks into delayed care.
It leaks into practice economics.
And eventually it can influence whether a practice can
continue offering services.
That is why revenue-cycle design isn't merely a finance
issue.
It is part of healthcare infrastructure.
The Future Will Not Be “More Billing”
It will be less visible billing.
The best systems should increasingly recognize problems
before humans have to chase them.
They should surface exceptions.
They should connect information.
They should make ownership obvious.
They should learn from recurring patterns.
They should reduce unnecessary handoffs.
They should allow humans to spend their time on the cases
that actually require judgment.
The ideal outcome?
Nobody celebrates the technology.
Nobody talks about the automation.
Nobody says:
“Look how sophisticated our RCM platform is.”
They simply notice:
“Why are we getting fewer annoying problems?”
That's the point.
What I Think We Have Been Getting Wrong
We have spent years asking:
How do we collect more revenue?
I think the better question is:
How do we create fewer reasons for revenue to get stuck?
Those sound similar.
They aren't.
The first question is downstream.
The second is upstream.
The first asks how to recover.
The second asks how to prevent.
The first creates more work.
The second tries to remove work.
And that's the shift I believe healthcare needs.
Sophia Had a Plan. Your Revenue Cycle Should Too.
Sophia's story is not a metaphor for billing.
It is a reminder about something more fundamental:
Disconnected information creates uncertainty. Connected
information creates the possibility of a plan.
Sophia's parents had been through uncertainty.
They had searched.
They had asked questions.
They had traveled.
They had pieced together clues.
When they reached a team experienced with ROHHAD, the pieces
began to make sense.
They had a plan.
Healthcare revenue cycles deserve the same discipline.
Not because billing is as important as a child's health.
It isn't.
But because healthcare cannot separate clinical care from
the systems that make care possible.
A physician cannot treat patients indefinitely in a practice
that cannot sustain itself.
A staff cannot spend every day repairing avoidable workflow
failures.
A patient should not have to become the messenger between
disconnected systems.
And a billing team should not have to be the archaeological
department of the entire practice.
The claim is where the problem becomes visible.
The workflow is where the problem begins.
That's where we should look.
The Question for Physicians and Clinic Owners
Here's the question I want to leave you with:
What problem does your billing team keep fixing that
should never have reached billing in the first place?
Not the biggest problem.
Not the most expensive problem.
The recurring problem.
The one everyone has learned to tolerate.
The one someone says:
“That's just how our system works.”
Those words should make every practice leader nervous.
Because sometimes:
“That's just how our system works”
really means:
“We've become very good at living with a preventable
problem.”
Tell me what yours is.
Leave a comment.
Share this with a physician, practice owner,
administrator or biller who is tired of fixing the same problem twice.
And if you believe healthcare should spend less time
compensating for broken workflows and more time preventing them, step into
the conversation.
Free Resource
Want to think about your revenue cycle from the upstream
rather than the downstream?
Check my Featured section on LinkedIn for a free
resource.
No signup needed.
PS: Free resource in Featured on LinkedIn.
Continue the Conversation
I write about the intersection of medicine, healthcare
operations, technology, revenue cycle and entrepreneurship.
About the Author
Dr. Daniel Cham is a physician, medical consultant
and entrepreneur working at the intersection of healthcare technology,
medical practice management and medical billing.
As founder of OnnX, he focuses on practical ways to improve
healthcare workflows, reduce administrative friction and help small and
medium-sized medical practices build more transparent, efficient and
data-driven revenue operations.
His work centers on one question:
How can healthcare organizations spend less time
compensating for broken workflows and more time improving the work itself?
Connect with Dr.
Daniel Cham on LinkedIn
Disclaimer
This article is for general educational and
informational purposes only. It is not medical, legal, compliance,
financial or professional advice. Healthcare organizations should consult
appropriately qualified professionals regarding their specific clinical,
operational, legal, regulatory and technology circumstances.
Sources
Boston Children's Hospital — “They had a plan”: How
Sophia's parents found care for ROHHAD syndrome. Published September 15,
2026.
Read the
Boston Children's Hospital story
American Medical Association — “AMA, state societies back
Patients First Act.” Published September 14, 2026. Quote from AMA President
Willie Underwood III, MD, MSc, MPH.
Healthcare Financial Management Association — 2026 Clean
Claims Study Brief. Research on claims automation, front-end claim
scrubbers and manual intervention.
Centers for Medicare & Medicaid Services — Electronic
Prior Authorization. Current CMS information on administrative burden,
electronic prior authorization and upcoming API requirements.
#Healthcare #MedicalBilling #RevenueCycleManagement #RCM
#Physicians #ClinicOwners #PrivatePractice #HealthcareOperations
#MedicalPracticeManagement #HealthcareTechnology #HealthcareAI #HealthTech
#Automation #Interoperability #RevenueIntegrity #DenialManagement
#PriorAuthorization #PatientExperience #HealthcareInnovation
#PhysicianEntrepreneur #DigitalHealth #HealthcareLeadership #OnnX
