Wednesday, August 26, 2026

Dáithí Mac Gabhann Got His New Heart. So Why Are We Still Making Healthcare This Hard?

Behind every claim, denial, authorization, and clinical note is a person waiting for something that matters. Dáithí's story reminds us who all that work is really for.



“AI has enormous potential in healthcare, but it cannot replace physician judgment.”
John Whyte, MD, MPH, CEO of the American Medical Association

 

A nine-year-old boy is playing football in his front garden in Ballymurphy, west Belfast.

His name is Dáithí Mac Gabhann.

A few months ago, that ordinary scene would have been almost unimaginable.

Dáithí was born with hypoplastic left heart syndrome, a serious congenital heart condition. He had been waiting for a heart transplant since 2018.

Eight years.

Think about that.

Eight years is almost an entire childhood.

While other children were worrying about homework, birthday parties and football practice, Dáithí and his parents, Máirtín Mac Gabhann and Seph Mac Gabhann, were waiting for a telephone call that could change everything.

The call finally came.

In July 2026, Dáithí received a heart transplant at Freeman Hospital in Newcastle upon Tyne.

Weeks later, he came home to Belfast.

And there he was.

Playing football.

His brother Cairbre was there too.

His family was finally able to imagine something that sounds almost embarrassingly ordinary:

A childhood.

The Irish News reported that Dáithí's return home marked the end of an almost eight-year journey. His father expressed gratitude to the donor family, whose identity remains private.

Here is the part that stayed with me.

Dáithí did not spend eight years waiting for better healthcare technology.

He did not spend eight years waiting for a new AI platform.

He did not spend eight years waiting for a more efficient revenue cycle.

He was waiting for a chance to live.

And that raises an uncomfortable question for everyone working in healthcare:

Why have we become so good at measuring healthcare that we sometimes forget what healthcare is actually for?


The controversial idea

Here is my contrarian view:

Medical billing is not the most important thing happening in a medical practice.

Obviously.

But it may be one of the most important things determining whether that practice can continue doing the most important thing.

That distinction matters.

Physicians sometimes talk about billing as if it were an annoying parasite attached to medicine.

I understand the feeling.

You went to medical school.

You trained for years.

You learned anatomy, physiology, pathology, pharmacology and clinical reasoning.

You did residency.

You took call.

You managed emergencies.

You learned how to make difficult decisions when the information was incomplete.

Nobody told you that one day you would spend part of your career trying to understand why a payer rejected a claim because of a modifier.

Welcome to modern medicine.

We somehow built a healthcare system in which a physician can save a patient's life in the morning and spend the afternoon arguing with a payer portal.

That is not a joke.

It is a design failure.

And we should stop pretending it is normal.


The billing department is not the problem

This may sound strange coming from someone building a medical billing company.

But I don't think the billing department is the problem.

The architecture is the problem.

We have separated clinical care from administrative infrastructure as if they were unrelated activities.

They aren't.

A physician sees a patient.

A clinical story is created.

That story becomes documentation.

The documentation becomes structured data.

The structured data becomes codes.

The codes become a claim.

The claim becomes a financial transaction.

The payer evaluates it.

Payment comes back.

Or it doesn't.

That is one chain.

We have simply given different parts of the chain different names.

Clinical.

Administrative.

Financial.

Operational.

Revenue cycle.

But the patient experiences only one thing:

healthcare.


The Dáithí test

I have started thinking about a simple test for healthcare technology.

I call it the Dáithí test.

Before we celebrate a new healthcare technology, ask:

Does this ultimately help someone get back to living?

Not every technology needs to improve survival.

Some technologies reduce errors.

Some reduce costs.

Some improve access.

Some help clinicians work faster.

All of those can matter.

But somewhere downstream, the purpose should connect to a human outcome.

For Dáithí, the outcome was wonderfully ordinary.

Walking.

Running.

Playing football.

Being with friends.

Going home.

That is the destination.

The paperwork is the road.

We should not confuse the road with the destination.


Healthcare has a strange addiction to paperwork

Let's be honest.

Healthcare has an almost supernatural ability to turn simple things into complicated workflows.

A patient needs care.

Someone asks for authorization.

Someone submits a form.

Someone calls.

Someone waits.

Someone sends records.

Someone asks for more records.

Someone resubmits.

Someone receives a denial.

Someone appeals.

Someone waits again.

Eventually someone says:

“Good news. It was approved.”

And everyone celebrates.

Why?

Because we successfully completed a process we designed ourselves.

That deserves some reflection.

We should not measure our brilliance by how efficiently we navigate unnecessary complexity.

We should measure our brilliance by how much unnecessary complexity we eliminate.

That is a very different philosophy.


The numbers are not funny

The humor disappears quickly when you look at the data.

The American Medical Association's 2026 physician survey found that:

95% of physicians said prior authorization delays necessary care.

79% said patients sometimes abandon treatment because of authorization challenges.

92% said prior authorization negatively affects clinical outcomes.

26% reported that prior authorization had contributed to a serious adverse event.

Physicians and staff reported completing an average of 40 prior authorizations per physician per week, consuming about 13 hours of physician and staff time each week.

And 94% said prior authorization contributes to burnout.

Forty authorizations.

Thirteen hours.

Every week.

For one physician.

That is not an administrative inconvenience.

That is an operating model.

And if your practice is paying someone to spend 13 hours every week fighting a system, that cost does not disappear.

Someone pays for it.

The practice.

The physician.

The staff.

The patient.

Or eventually the healthcare system.


Here is the part people get wrong about AI

The answer is not:

“Let's put AI on it.”

That sentence should make every physician slightly nervous.

Because AI can automate a bad process.

It can automate an inaccurate process.

It can automate an inefficient process.

It can automate a workflow that nobody should have designed in the first place.

And now the bad process happens faster.

Congratulations.

We invented the world's fastest bureaucratic machine.

That is not innovation.

It is automation theater.


AI should not make bad billing faster

This is one of the strongest beliefs behind my work with OnnX.

I am not interested in AI simply because AI is popular.

I am interested in whether intelligence can be moved to the right point in the workflow.

That distinction is critical.

Suppose a claim is denied because information was missing.

Traditional thinking asks:

How can we process the denial faster?

Better thinking asks:

Why didn't we identify the problem before the claim was submitted?

That is the difference between downstream repair and upstream prevention.

And I believe healthcare has an enormous opportunity here.


Precision at the source

I call the concept precision at the source.

The basic idea:

The earlier you identify a predictable problem, the cheaper and easier it usually is to fix.

If a documentation problem is discovered after a denial, someone has to investigate.

If it is discovered before submission, the fix may take seconds.

If an authorization problem is discovered after a procedure, the situation can become painful.

If it is identified before the appointment, the practice has options.

If a coding inconsistency is identified after payment is delayed, staff must chase it.

If it is identified before submission, the problem may never leave the building.

This is not revolutionary technology.

It is basic systems thinking.

Yet healthcare often does the opposite.

We wait for the failure.

Then we build a department to manage the failure.

Then we build software to manage the department.

Then we build AI to manage the software.

At some point, we should probably ask:

What if we just prevented the failure?


A physician's day is not an API

Here is another contrarian thought.

Healthcare technology companies sometimes talk about physicians as if they were APIs.

Input.

Process.

Output.

Patient enters.

Documentation generated.

Code assigned.

Claim submitted.

Revenue collected.

Beautiful.

Except humans don't work that way.

Physicians are constantly making judgments.

Patients change their stories.

Clinical situations are messy.

Documentation varies.

Payers change rules.

Exceptions happen.

And sometimes the most important information is not the information that fits neatly into a database.

That is why healthcare AI needs humility.

The system should know when it knows.

And it should know when it does not.


The goal is not autonomous medicine

I am particularly skeptical of the phrase:

“Fully autonomous healthcare.”

Maybe someday.

But today?

I would rather have appropriately supervised intelligence than impressive autonomy.

In medical billing, AI should help with:

Pattern recognition.

Documentation support.

Coding assistance.

Claim validation.

Payer-rule interpretation.

Denial analysis.

Workflow prioritization.

Exception detection.

Appeal preparation.

But when the consequences become significant, humans should remain appropriately involved.

That is not a weakness of AI.

It is good system design.


The physician does not need another dashboard

Please.

No more dashboards just because dashboards are easy to build.

A physician-owner does not wake up thinking:

“I wish I had three more colorful graphs.”

They want answers.

Why is revenue down?

Why are denials increasing?

Which payer is causing the problem?

Why is this service line underperforming?

How many staff hours are being wasted?

Which claims require attention?

What should we fix first?

A good system should answer those questions.

A great system may answer them before the physician asks.


What physicians actually want

Talk to physicians long enough and you discover something interesting.

They usually don't ask for more technology.

They ask for less friction.

They want:

Fewer phone calls.

Fewer portals.

Fewer denials.

Fewer surprises.

Fewer repetitive tasks.

Less documentation after hours.

Less chasing.

More visibility.

More control.

More time with patients.

That is the product brief.

Everything else is implementation detail.


The biggest billing mistake I see

It is not bad coding.

It is not slow claims.

It is not even denials.

It is finding problems too late.

Think about it.

A practice discovers an error after the claim is rejected.

Why?

Because that is where the system finally became smart enough to notice.

That is backwards.

The revenue cycle should be increasingly intelligent before the claim reaches the payer.

Not because we want to manipulate the payer.

Because we want the claim to accurately represent the care that actually occurred.

That is an important ethical distinction.


The objective is not “get the claim paid”

This may be the most provocative statement in the article:

Getting every claim paid is not the goal.

Accurate payment for legitimate care is the goal.

Those are not identical.

If a claim is unsupported, the right answer is not to find a clever way around the payer.

If documentation does not support a code, the answer is not aggressive automation.

If a service was not medically necessary, technology should not manufacture justification.

The goal is accuracy.

Accuracy protects the patient.

Accuracy protects the physician.

Accuracy protects the practice.

Accuracy protects the healthcare system.


Three experts. Three lessons.

1. William Osler: remember the human being

Osler's philosophy remains useful because it forces us back toward the patient.

The disease is not the person.

The code is not the patient.

The claim is not the patient.

The patient is the patient.

That sounds obvious.

Healthcare needs reminding.

2. The AMA: administrative burden is becoming clinical burden

The AMA's latest survey demonstrates that prior authorization is consuming substantial physician and staff time while physicians report delays, treatment abandonment and adverse events.

The lesson is not simply:

“Insurance companies are bad.”

That is too easy.

The deeper lesson is:

Administrative friction can become a clinical variable.

That means physician leaders should start treating administrative performance as part of operational quality.

3. CMS: the future is increasingly structured

CMS has been moving toward greater electronic prior authorization, interoperability and more specific explanations for certain denials.

Under CMS's prior authorization rule, impacted payers are required to provide specific reasons for certain denied requests and meet defined decision timeframes.

That matters.

Because the future of healthcare administration is becoming more structured.

The opportunity is not simply to digitize paper.

It is to make structured information useful.


The hidden opportunity for independent practices

Large health systems have scale.

Independent practices have something else:

clarity.

When a practice has 12 employees, everyone notices when something goes wrong.

A denied claim is not just a statistic.

It is someone's afternoon.

A prior authorization is not just a workflow.

It is someone's phone call.

A payer portal is not just software.

It is someone's headache.

That makes independent practices excellent laboratories for healthcare innovation.

If we can reduce friction there, we are solving something real.


Five questions before you buy another billing product

Before a vendor shows you a beautiful demo, ask five questions.

1. What problem are you solving?

If the answer is “AI-powered revenue cycle optimization,” ask again.

What problem?

2. Where does the intervention occur?

Before documentation?

During documentation?

Before claim submission?

After denial?

3. What happens when the AI is wrong?

This question is often more revealing than the demo.

4. Can I measure the improvement?

If the vendor cannot define the baseline and outcome, be careful.

5. Does this reduce work or redistribute work?

This is the trap.

A system can make one department faster while creating more work somewhere else.

The total workflow is what matters.


The five metrics I would watch

Forget vanity metrics.

Start with:

Clean claim rate

How often do claims leave correctly the first time?

Denial rate

How often does the payer reject the claim?

Preventable denial rate

How many denials could the practice reasonably have prevented?

Days in A/R

How long is money sitting unresolved?

Administrative hours per 100 claims

This last metric is underrated.

Revenue is important.

But time is also money.

And physician time is particularly expensive.


A better definition of ROI

Healthcare technology companies love saying:

“We save practices money.”

Fine.

Show me.

I want to see:

Baseline.

Intervention.

Result.

If staff previously spent 100 hours per month on a workflow and now spend 60, show it.

If denials were 9% and become 6%, show it.

If days in A/R decline, show it.

If physicians spend less time on administrative tasks, show it.

If nothing improves, say so.

Trust grows faster when companies admit what did not work.

That applies to founders too.


A failure worth admitting

Healthcare entrepreneurs sometimes fall into the same trap as healthcare institutions.

We start with the solution.

Then we look for the problem.

It is seductive.

The demo looks great.

The AI responds.

The workflow moves.

Everyone nods.

Then the real clinic gets involved.

And someone says:

“This creates three extra clicks.”

And suddenly the brilliant solution has become another burden.

That is a useful failure.

Because the lesson is simple:

A workflow that looks elegant on a whiteboard can be terrible at 4:47 p.m. on a Friday when the clinic is full.

The real test is not the demo.

It is Tuesday afternoon.


The humor of healthcare technology

There is an old joke in healthcare:

We have invented technology to save doctors time.

Then we spend three hours teaching doctors how to use it.

Healthcare technology sometimes resembles buying a robot vacuum and then spending the afternoon explaining to the robot where the floor is.

At some point, we need better design.

The best automation should not require a PhD in automation.

It should simply work.


What “good AI” should feel like

Good AI should feel less like a new employee and more like a competent assistant.

It notices.

It remembers.

It prioritizes.

It flags.

It explains.

It stays quiet when nothing needs attention.

That last one matters.

Silence is a feature.

If the system is constantly interrupting the physician, it is not intelligent enough.


The myth-buster

Myth 1: AI will eliminate the billing department

Probably not.

And that should not be the goal.

The better goal is to eliminate unnecessary work.

Human beings should handle judgment, exceptions, relationships and accountability.

Machines should handle repetitive, structured tasks where they can do so reliably.

 

Myth 2: More documentation prevents more denials

Not necessarily.

More documentation can also mean more burden and more opportunities for inconsistency.

The objective is accurate and relevant documentation, not maximal documentation.

 

Myth 3: Every denial is bad

No.

Some denials are appropriate.

The question is whether the denial is accurate and whether the practice can understand why it occurred.

 

Myth 4: Faster claims equal better revenue

Not always.

A practice can submit claims faster and still collect poorly.

The real question is:

How much legitimate revenue becomes collectible, and how quickly?

 

Myth 5: The newest AI model wins

No.

The workflow wins.

A mediocre model embedded beautifully into a workflow can be more valuable than an extraordinary model nobody wants to use.


Recent news: the system is starting to catch up

There is an interesting tension in healthcare right now.

Physicians are saying:

This administrative burden is hurting us.

Regulators are saying:

We need more interoperability and transparency.

Technology companies are saying:

AI can help.

And patients are saying:

I just want my care.

Those four voices need to meet.

The AMA's 2026 survey found that only 33% of physicians believe recent insurer commitments will make a meaningful difference.

That skepticism is important.

Healthcare leaders should not respond with another promise.

They should respond with measurement.

Show physicians what changed.


Legal and ethical reality

There is no shortcut around compliance.

AI-assisted billing still requires appropriate attention to:

HIPAA

Business associate obligations

Coding compliance

Payer contracts

Documentation requirements

Fraud and abuse laws

Auditability

Data security

Human oversight

And there is a fundamental ethical principle:

Never let an algorithm's confidence become a substitute for evidence.

If the documentation does not support something, AI should not manufacture support.

If the system is uncertain, it should say so.

If the recommendation matters, the practice should be able to understand how it was generated.

That is not merely good engineering.

It is good medicine.


A 30-day challenge for physician-owners

You do not need a six-month transformation project.

Try this.

Days 1–7: Find the leaks

Pull your denial data.

Find the five largest categories.

Calculate how much revenue is sitting in unresolved claims.

Days 8–14: Find the cause

For each major denial, ask:

Where did it begin?

Documentation?

Eligibility?

Authorization?

Coding?

Payer rule?

Claim formatting?

Workflow?

Days 15–21: Move upstream

Pick one recurring problem.

Try to catch it earlier.

Not ten problems.

One.

Days 22–30: Measure

Did the denial rate change?

Did staff hours change?

Did A/R change?

Did physician burden change?

If yes, expand.

If no, learn.

Then try again.

That is innovation.

Not buying software.

Learning faster.


What OnnX is trying to build

This is where my own work comes in.

I founded OnnX around a question:

What if medical billing became intelligent before the claim was created?

Not another outsourcing company.

Not another portal.

Not another dashboard.

Not AI for the sake of putting “AI” on a website.

The goal is to explore an AI-powered medical billing infrastructure that helps small and medium-sized practices identify problems earlier, understand their revenue cycle better and reduce unnecessary administrative work.

The philosophy is upstream.

Clinical information → structured intelligence → validation → optimized claim → payer interaction → payment.

The closer we can connect those stages, the less information should be lost between them.

That is the thesis.

It is still being built.

And it should be challenged.

Because healthcare founders should not expect physicians to believe a vision simply because it sounds good.

The product has to earn that belief.


The bigger idea: healthcare infrastructure should disappear

Think about electricity.

You don't walk into a room and congratulate the electrical grid.

It works.

Think about the internet.

Most of the time, you don't think about the routing infrastructure.

It works.

Healthcare administration should move in that direction.

The physician should not have to think about the revenue-cycle machinery every time a patient walks through the door.

The infrastructure should quietly do its job.

When something requires human intervention, it should explain why.

That is the future I want to see.

Invisible infrastructure.

Not invisible accountability.

Not invisible algorithms.

Invisible friction.


Why this matters for physician independence

This conversation is bigger than billing.

It is about whether physicians can operate sustainable practices without surrendering more and more control to layers of intermediaries.

When a physician cannot see where revenue is being lost, the practice becomes dependent.

When the physician cannot understand why claims are denied, the practice becomes dependent.

When every workflow requires another vendor, another portal and another contract, complexity compounds.

Better infrastructure should give practices more agency, not less.

That is especially important for small and medium-sized clinics.


The patient is still the point

Let's go back to Belfast.

Dáithí Mac Gabhann came home.

He was playing football.

That is the image I want healthcare leaders to remember.

Not the transplant statistics.

Not the waiting list.

Not the legislation.

Not the technology.

The boy.

The football.

The family.

The ordinary day.

That is what successful healthcare eventually looks like.

The patient stops thinking about healthcare.

They start living.

That should be our definition of success.


The three lessons I would take from Dáithí's story

Lesson 1: Healthcare should end in life, not paperwork

The paperwork is necessary.

But it is not the outcome.

Lesson 2: Waiting is a healthcare variable

Patients wait for appointments.

They wait for authorizations.

They wait for referrals.

They wait for payments to settle.

They wait for answers.

Every unnecessary delay has a human cost.

Lesson 3: The best innovation removes friction between people and life

That is the standard I would use.

Not:

“Does it use AI?”

Instead:

“Does it make healthcare easier to deliver and easier to receive?”


Final Thoughts: Stop Optimizing the Wrong Thing

Healthcare has become remarkably good at optimizing processes that should never have become this complicated.

We optimize claim submission.

We optimize denial management.

We optimize authorization workflows.

We optimize staff productivity.

We optimize documentation.

We optimize dashboards.

We optimize utilization.

We optimize everything.

Except sometimes the thing that matters most.

The patient's ability to get on with life.

Dáithí Mac Gabhann waited eight years for a heart.

Now he is home in west Belfast.

He can play football.

His family can think about tomorrow.

And somewhere in that story is a lesson for every healthcare entrepreneur, administrator and physician-owner:

The purpose of healthcare is not to create better paperwork.

It is to create better outcomes for human beings.

The administrative system should serve that purpose.

Not become the purpose.


Get Involved

So here is my question for physicians and clinic owners:

If you could eliminate one administrative burden from your practice tomorrow, what would it be?

Prior authorization?

Denials?

Documentation?

Payer portals?

Eligibility?

Coding?

A/R?

Or something nobody outside your practice even knows exists?

Tell me in the comments.

Your answer may reveal a problem that thousands of other practices are quietly experiencing.

And if this perspective resonates with you, share the post with another physician or clinic owner who has spent too much time fighting the system instead of caring for patients.

The future of healthcare will not be designed only by technology companies.

It will be shaped by the people who live with the problems every day.

Raise your hand. Join the conversation. Help define what better healthcare infrastructure should look like.


Three Actions

Measure one source of administrative friction.

Move one recurring problem upstream.

Share what you learn with the healthcare community.

Small changes compound.

Better questions produce better systems.

And better systems give clinicians more time to do what only humans can do.


Frequently Asked Questions

Is medical billing really connected to patient care?

Indirectly, yes.

Billing affects practice sustainability, staffing, administrative capacity and sometimes delays in care. It should not replace clinical quality measures, but it is part of the infrastructure supporting care.

Should physicians become billing experts?

No.

Physician-owners should understand the major financial and operational drivers of their practices. They should not have to become professional coders.

Can AI eliminate denials?

No credible technology should promise zero denials.

The better objective is reducing preventable denials and identifying patterns earlier.

Should every clinic adopt AI?

No.

Start with the problem.

If you do not know what is broken, buying AI is probably premature.

What should I ask an AI billing vendor?

Ask:

What problem will you solve?

Where in the workflow will you solve it?

What is the baseline?

What is the measurable outcome?

What happens when the system is wrong?

Is more documentation better?

Not automatically.

The goal is accurate, relevant documentation that supports the care provided.

What is “precision at the source”?

It means identifying and correcting predictable problems as close as possible to where the underlying information is created rather than waiting until the claim is denied.

What is the biggest mistake practices make?

Treating every denial as an individual problem instead of looking for recurring patterns.

What should I measure first?

Start with clean claim rate, denial rate, preventable denial categories, days in A/R and staff time spent on billing problems.

What does good healthcare AI look like?

It should be useful, explainable, measurable, secure and appropriately supervised.

And ideally, it should create fewer interruptions rather than more.


References

1. Dáithí Mac Gabhann's homecoming: Current reporting describes Dáithí returning to west Belfast after his heart transplant and the significance of an ordinary childhood finally becoming possible.
Read the Irish News report on Dáithí's return home

2. Physician burden from prior authorization: The AMA's 2026 survey provides current data on delays, abandonment of treatment, adverse events, physician workload and burnout.
Read the AMA 2026 prior authorization findings

3. CMS and the changing administrative infrastructure: CMS's interoperability and prior authorization framework points toward more electronic workflows and greater transparency around certain denial decisions.
Read the CMS prior authorization final rule


About the Author

Dr. Daniel Cham is a physician, medical consultant and healthcare technology entrepreneur whose work sits at the intersection of medicine, healthcare operations, medical billing and technology.

He is the founder of OnnX, an AI-powered medical billing SaaS initiative focused on helping small and medium-sized physician practices reduce administrative friction, improve revenue-cycle intelligence and gain greater visibility into the operational side of their practices.

His approach is intentionally practical:

Technology should solve a problem before it becomes a product.

His work explores how healthcare organizations can use intelligent automation without losing clinical judgment, human accountability or the patient connection at the center of medicine.
Dr. Daniel Cham on LinkedIn


Disclaimer / Note

This article is intended for general educational and informational purposes. It does not constitute medical, legal, coding, compliance, reimbursement, financial or professional advice. Healthcare organizations should consider their own circumstances and seek advice from appropriately qualified professionals before making clinical, legal, compliance or operational decisions.


Continue the Conversation

The healthcare problems worth solving are not always the ones receiving the most attention.

I share observations, practical strategies and lessons from the intersection of clinical medicine, healthcare operations, technology and entrepreneurship.

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If the topic of medical billing, healthcare operations, AI or practice innovation matters to you, take a look and use whatever is useful for your practice.


One Last Thought

Dáithí's story gives us a beautiful but uncomfortable benchmark.

A child waited eight years for a new heart.

Healthcare professionals fought to keep him alive.

A donor family made an extraordinary gift.

His parents, Máirtín Mac Gabhann and Seph Mac Gabhann, spent years advocating for organ donation.

And now Dáithí is home.

Playing football.

That is the outcome.

Everything else is infrastructure.

Let's build infrastructure that gets out of the way.

Let's give physicians more time for medicine and patients more time for life.

And let's stop confusing a perfectly processed claim with a perfectly delivered healthcare system.

If this perspective resonates, repost it so another physician or clinic owner can join the conversation.

#Healthcare #MedicalBilling #RevenueCycleManagement #HealthcareInnovation #HealthcareAI #PhysicianEntrepreneur #PrivatePractice #PhysicianOwnedPractice #HealthcareTechnology #MedicalPracticeManagement #PriorAuthorization #DenialManagement #MedicalCoding #HealthcareOperations #ClinicalWorkflow #HealthTech #DigitalHealth #AIinHealthcare #PatientCenteredCare #AdministrativeBurden #IndependentPhysicians #MedicalSaaS #RevenueCycle #HealthIT #Interoperability #PracticeManagement #OnnX

 

Tuesday, August 25, 2026

Ericka Akoto's Couch, the $10 Billion Question, and Why Your Billing Problem May Not Be a Billing Problem

The billing department may be where the problem appears. But it may have started long before the claim was ever submitted.



“Healthcare delivery inherently requires a human touch.” — Dr. John Whyte, CEO, American Medical Association

A patient. A couch. A physical therapist. And a lesson that may completely change how physicians think about medical billing.


It started with a couch

Ericka Akoto lives in Hopewell, Virginia.

Her home is her safe place.

Her 2-year-old Silky Terrier, Hazel, helps with that.

But in March, Ericka had to leave home and go to VCU Medical Center in Richmond after fluid began building up in her leg and foot because of congestive heart failure.

She had already been through hospitalizations before.

She knew the routine.

Hospital bed.

Monitors.

Questions.

Rounds.

Waiting.

Discharge.

And, as she described it, she had previously gone home while still struggling with symptoms.

Then VCU Health offered her something different.

Hospital at Home.

Instead of bringing Ericka into a hospital and trying to make her fit into the hospital's environment, the care team brought hospital-level care into hers.

And something interesting happened.

The clinicians could see things they might never have seen inside a hospital.

Including a problem with her favorite couch.

Ericka had experienced two strokes, and moving around her home had become more difficult.

A physical therapist noticed that she struggled to get up from the couch.

The solution wasn't a $500,000 medical device.

It wasn't generative AI.

It wasn't blockchain.

It wasn't a new digital health platform with 47 features and a dashboard nobody opens.

It was a cushion and handles near the armrest.

Simple.

Practical.

Human.

And Ericka said something that should make every healthcare executive stop scrolling:

“It just made me, as a patient, feel valued and that my healthcare was truly important.”

That sentence is bigger than hospital-at-home care.

It is a lesson about the entire healthcare system.

And it has an uncomfortable implication for medical billing.

The most important information about a patient isn't always in the chart.

Sometimes it's on the couch.

And sometimes the information determining whether your practice gets paid isn't in the billing system either.

It is upstream.


Here's my contrarian take

Most medical practices don't have a billing problem.

They have a visibility problem.

And then they hire someone to work harder inside the billing problem.

That's different.

A claim gets denied.

Someone investigates it.

Someone calls the payer.

Someone opens a portal.

Someone sends records.

Someone appeals.

Someone waits.

Someone follows up.

Someone sends another fax.

Eventually, someone gets paid.

Everyone celebrates.

Until the same denial happens again.

Congratulations.

You successfully repaired the symptom.

The disease is still there.


We have built an industry around fixing yesterday

Think about how absurd this is.

A patient sees a physician today.

The encounter creates information.

That information becomes documentation.

Documentation becomes coding.

Coding becomes a claim.

The claim reaches the payer.

The payer rejects it.

And weeks later, somebody discovers that something was missing.

Then we call the billing department.

Why?

Because the billing department is where the problem became visible.

But that doesn't mean the billing department created it.

This is one of the biggest mistakes in revenue cycle management.

We confuse the location where a problem is discovered with the location where it was created.

Those are not necessarily the same place.


Ericka's couch is actually a data-quality story

Stay with me.

The couch matters because the physical therapist saw something that a traditional clinical encounter might have missed.

The patient could describe the problem.

But seeing the problem was different.

Observation created context.

And context changed the intervention.

This is precisely what happens in revenue cycle management.

A billing system might tell you:

Claim denied.

That's observation.

Useful.

But incomplete.

The real question is:

Why?

Maybe eligibility was wrong.

Maybe authorization was missing.

Maybe the diagnosis didn't support the service.

Maybe documentation was incomplete.

Maybe the wrong modifier was used.

Maybe the payer's policy changed.

Maybe the information was entered incorrectly three steps earlier.

The denial is the symptom.

The workflow is the environment.


The $10 billion question

Here's the question I would ask every physician-owner:

How much revenue are you losing because your practice discovers errors after the point where they were cheapest to fix?

I don't mean one dramatic billing mistake.

I mean thousands of tiny leaks.

An eligibility error here.

A missing authorization there.

A documentation mismatch.

A coding inconsistency.

A claim submitted late.

A payer-specific rule nobody noticed.

A denial that gets appealed instead of prevented.

None of these individually looks catastrophic.

Together?

They can become a serious operating problem.

And the irony is that practices often respond by hiring more people to manually chase the consequences.

That's like putting another person at the bottom of a leaky boat.

Useful?

Maybe.

But eventually someone should probably look for the hole.


The healthcare industry's favorite phrase: "That's just how it works"

Physicians hear it.

Practice managers hear it.

Billers hear it.

Patients hear it.

“That's just how insurance works.”

“That's just how prior authorization works.”

“That's just how the payer portal works.”

“That's just how the EHR works.”

“That's just how billing works.”

I have a problem with that phrase.

Because sometimes “that's just how it works” really means “we've stopped questioning the workflow.”


The physician's hidden second shift

There is another problem.

Physicians aren't only practicing medicine anymore.

They are increasingly becoming unpaid operations staff.

The physician sees the patient.

Then documents the encounter.

Then responds to messages.

Then reviews results.

Then handles prior authorization.

Then deals with a coding question.

Then answers the billing team's question.

Then goes home.

And opens the laptop.

Again.

The phrase “pajama time” has become almost normal in healthcare.

That's not normal.

It's just familiar.

There is a difference.


Here's where I disagree with conventional RCM thinking

The traditional revenue-cycle conversation often sounds like this:

How do we collect more?

My question is different:

Why did we create so much work to collect it in the first place?

That's not semantics.

It's architecture.

If the workflow produces bad information, the billing department becomes a cleanup operation.

If the workflow produces good information, billing becomes much more predictable.

The goal should not be to build the world's most efficient cleanup crew.

The goal should be to create less mess.


Expert #1: Dr. Julia Breton

Dr. Julia Breton, co-medical director of VCU Health Hospital at Home, describes an important difference between hospital-based care and home-based care.

At home, clinicians can see how patients actually live.

They can see medication organization.

They can see mobility challenges.

They can involve family.

They can understand the environment.

Breton describes the goal beautifully:

The job is not to make the home more like a hospital. It is to make the hospital more like home.

That principle has implications for technology.

Healthcare software shouldn't force physicians to behave like data-entry clerks.

It should adapt to clinical workflows.

The technology should work around the physician.

Not the physician around the technology.


Expert #2: Chris Walker, R.N.

Chris Walker, R.N., a VCU Hospital at Home nurse, describes another advantage.

In a hospital, clinicians can be pulled in multiple directions.

At home, he can focus on one patient.

That sounds simple.

But it reveals a powerful operational principle:

Attention is a resource.

The same is true in a medical practice.

If your staff spends hours manually checking claims, portals, eligibility, spreadsheets, and denial queues, those people have less attention available for higher-value work.

Automation isn't really about eliminating humans.

It's about deciding where human attention is worth spending.

That is a much more useful definition of AI.


Expert #3: The patient herself

The third expert isn't a CEO.

Isn't a consultant.

Isn't a technology founder.

It's Ericka Akoto.

Her lesson is the most important one.

She said that being treated at home allowed clinicians to see what she dealt with every day.

That changed the care she received.

The implication for healthcare technology is profound:

Patients don't experience healthcare as a series of databases.

They experience it as life.

A couch.

A medication bottle.

A worried spouse.

A difficult staircase.

A confusing bill.

A phone call nobody returned.

A physician who listened.

A physician who didn't.

Healthcare technology that ignores this context can be technically sophisticated and still clinically stupid.


What physician-owned practices should steal from this story

Not the Hospital at Home model.

The design philosophy.

See the environment.

Find the signal.

Understand the context.

Fix the problem where it starts.

Don't wait for the failure report.

That is exactly how I think about revenue cycle.


The denial is not the problem

This may be the most important sentence in the article:

A denial is an outcome, not a root cause.

Yet we often manage denials as though they are the disease.

The claim appears.

The denial appears.

The biller works it.

Done.

But what happens next?

Another claim.

Same payer.

Same service.

Same problem.

Another denial.

Another work queue.

Another phone call.

Another afternoon.

Eventually somebody says:

“Why do we keep getting these?”

Exactly.

That's the question that should have been asked first.


Denial management vs. denial prevention

There is nothing wrong with denial management.

You need it.

Claims will fail.

Payers will make mistakes.

Patients will change insurance.

Rules will be misunderstood.

Technology will fail.

Humans will make mistakes.

But if your entire RCM strategy is built around repairing denials, you're operating downstream.

A better model is:

Detect → Understand → Prevent → Monitor

Instead of:

Deny → Work → Appeal → Wait → Repeat

One is a learning system.

The other is a hamster wheel with a clearinghouse login.


The five signals I'd watch first

If I owned a physician practice today, I'd start here.

1. Eligibility exceptions

How many claims are affected because coverage wasn't properly verified?

Don't just measure the number.

Find the pattern.

 

2. Authorization failures

Which procedures, payers, physicians, or locations generate the most authorization problems?

If the same pattern repeats, you don't have an employee problem.

You have a workflow problem.

 

3. Documentation-related denials

Are physicians repeatedly being asked for the same missing information?

If yes, ask why the workflow doesn't surface that requirement earlier.

 

4. First-pass claim performance

The first submission tells you something.

A claim that succeeds immediately is operationally different from one that requires three touches.

Track the difference.

 

5. Denial concentration

If 70% of your denials come from a small number of causes, stop treating 100 denial codes as 100 separate problems.

Find the few causes creating the majority of the pain.


Don't build another dashboard

I can already hear someone saying:

“Great. We'll build a dashboard.”

No.

Please don't.

Healthcare has enough dashboards.

We have dashboards looking at dashboards.

The real question isn't:

Can we see the problem?

It's:

Can we do something about it before it becomes a problem?

A dashboard tells you the house is on fire.

An intelligent workflow should ideally notice smoke.


AI's biggest opportunity in RCM isn't writing emails

Generative AI can write emails.

Wonderful.

It can summarize documents.

Great.

It can draft an appeal letter.

Useful.

But those aren't necessarily the highest-value applications.

The bigger opportunity is pattern recognition across fragmented workflows.

Imagine an AI system noticing:

“This payer has rejected 18 similar claims over the past 30 days. The common factor is a missing documentation element. Most originated from two physicians and one scheduling workflow.”

That's useful.

Now imagine it identifies the issue before submission.

That's better.

Now imagine it automatically alerts the appropriate team.

That's even better.

Now imagine the system learns whether the intervention worked.

Now we're getting somewhere.


The AI test I would use

Don't ask:

“Does your platform use AI?”

Almost everybody says yes.

Ask:

“What decision does the AI improve?”

Then ask:

“What happens differently because of it?”

Then:

“Can you measure the result?”

If the answer is vague, you may be looking at AI decoration.

And healthcare does not need more decoration.


My own failure lesson

I have spent enough time around healthcare technology to know that building a technically impressive product is not the same as solving a meaningful problem.

Healthcare founders love features.

We love integrations.

We love architecture.

We love saying “AI-powered.”

We love the demo.

But physicians don't wake up thinking:

“I hope someone gives me another dashboard today.”

They wake up thinking:

“I have 37 patients, six messages, two prior authorizations, a full clinic, and somehow I still need to finish yesterday's notes.”

That is the product problem.

Not the demo.


This is why I founded OnnX

My thesis behind OnnX is deliberately simple.

Medical billing should not require physicians to manage an ecosystem of disconnected middlemen, portals, spreadsheets, phone calls, and manual work queues.

For small and medium-sized physician-owned clinics, administrative complexity can become disproportionately expensive.

The answer isn't necessarily another employee.

And it isn't necessarily another piece of software.

The answer is a more intelligent operating layer.

One that connects the signals.

Finds the exceptions.

Automates repetitive work.

Surfaces root causes.

And helps prevent avoidable problems.

The goal is not to make physicians better billers.

The goal is to make billing less of the physician's problem.


A practical experiment for your practice

Don't buy anything.

Don't call a vendor.

Don't launch an AI project.

Do this first.

Take your top 20 recent denials.

Put them on a table.

For each one, ask:

Where was the problem created?

Not:

“Who fixed it?”

Ask:

Where did it begin?

Then categorize the answer:

Scheduling.

Registration.

Eligibility.

Authorization.

Clinical documentation.

Coding.

Claim creation.

Payer processing.

Appeal.

Patient responsibility.

You may discover something uncomfortable.

The billing department may be fixing problems it never created.

That's valuable information.


Then ask the $64,000 question

Not literally $64,000.

Unless that's what you're losing.

Ask:

What would happen if we prevented half of these problems before they reached billing?

Calculate:

Labor saved.

Revenue accelerated.

Appeals avoided.

Patient calls avoided.

Physician interruptions avoided.

A/R reduced.

Staff capacity recovered.

Now you have a business case.

Not a technology case.


The statistics tell part of the story

Current healthcare trends reinforce this larger shift.

VCU Health says its Hospital at Home program has cared for more than 1,000 people since launching in 2023. Patients receive virtual physician visits, in-person visits, and 24/7 virtual nursing support.

The broader hospital-at-home model is also expanding. The American Hospital Association reports that hundreds of hospitals across dozens of health systems and states have received approval to provide hospital-level care at home, while CMS has found generally positive outcomes and patient experiences in its evaluation.

At the same time, healthcare demand is shifting toward outpatient and home-based care. The AHA's 2026 forecast projects 20% growth in outpatient volumes by 2036, while post-acute care is projected to grow 31%.

The direction is clear.

Healthcare is becoming more distributed.

Which means information becomes more distributed too.

That makes interoperability, context, and workflow intelligence more important—not less.


And here's the uncomfortable part

The more healthcare moves outside the hospital, the less useful a healthcare architecture becomes if it assumes the hospital is the center of everything.

The same applies to billing.

If your RCM architecture assumes the billing department is the center of the revenue cycle, you're already looking backward.

The center is the patient journey.

Billing is one consequence of that journey.


The new RCM model

I believe we should think about revenue cycle differently.

Old model

Patient.

Encounter.

Claim.

Denial.

Biller.

Appeal.

Payment.

Better model

Patient.

Signal.

Validation.

Clinical documentation.

Intelligent claim preparation.

Payer response.

Continuous learning.

Prevention.

The difference is subtle.

But strategically enormous.


Myth Buster

Myth: “More billers means fewer billing problems.”

Sometimes.

But more people can also mean more handoffs.

Headcount is not the same thing as capacity.

 

Myth: “Our EHR already contains all the information.”

Technically?

Maybe.

Operationally?

That's a different question.

Information trapped inside a system isn't necessarily usable information.

 

Myth: “AI will solve our denials.”

Not automatically.

If the workflow is broken, AI can simply help you process the broken workflow faster.

AI needs good architecture.

 

Myth: “Physicians don't care about revenue cycle.”

Physicians may not want to spend their evenings thinking about claims.

That's different.

Physician owners absolutely care about whether their practice can remain financially healthy.

 

Myth: “The billing department owns the revenue cycle.”

No.

The revenue cycle crosses the entire organization.

Billing is where the financial consequences become visible.


The legal and compliance reality

There is a serious side to all this.

Automation should never become an excuse to manufacture documentation, manipulate coding, or optimize reimbursement at the expense of clinical truth.

AI should support legitimate healthcare operations.

It should not invent medical facts.

It should not create false justification.

It should not turn a reimbursement goal into a clinical decision.

And practices need to understand how vendors handle protected health information.

HHS notes that functions such as billing, claims processing, practice management, and data analysis may involve business-associate obligations under HIPAA when performed on behalf of covered entities.

Before implementing technology, practices should ask about:

HIPAA

Business Associate Agreements

PHI access

Audit logs

Encryption

Data retention

Subcontractors

AI training and data use

Human oversight

Data portability

Incident response

The cheapest vendor is not necessarily the cheapest decision.


The ethical question

Here's the ethical line I would draw:

Use technology to reduce friction around legitimate care.

Don't use it to manipulate the meaning of care.

That distinction matters.

We should optimize:

Workflow.

Accuracy.

Speed.

Transparency.

Patient experience.

Administrative burden.

We should never optimize the clinical story to fit the reimbursement.


What healthcare founders should learn from Ericka

If you're building healthcare technology, go watch healthcare happen.

Not a conference.

Not a pitch deck.

Not a demo.

Go where the patient is.

Watch the nurse.

Watch the physician.

Watch the scheduler.

Watch the biller.

Watch what happens after the patient leaves.

You will probably discover that the workflow in your product roadmap isn't the workflow in real life.

That's not a failure.

That's research.

The couch taught VCU something.

The billing queue can teach you something too.


What physician leaders should learn

Don't ask only:

“How much did we collect?”

Ask:

“What made collecting it difficult?”

That question changes the conversation.

It moves you from finance to operations.

From operations to workflow.

From workflow to root cause.

And from root cause to prevention.

That is where the leverage lives.


A 30-day RCM challenge

Week 1: Observe

Map the entire revenue cycle.

Don't change anything.

Just observe.

 

Week 2: Find

Identify the five most expensive recurring failure points.

 

Week 3: Fix

Choose one.

Fix the upstream workflow.

Not the downstream symptom.

 

Week 4: Measure

Compare:

Denial rate.

First-pass acceptance.

A/R.

Staff touches.

Appeals.

Administrative hours.

Then ask:

Did we actually make the system better?


The metrics I would put on the wall

Not 50 metrics.

Five.

First-pass claim rate

Denial rate

Top denial cause

Days in A/R

Administrative hours per 100 encounters

And one more:

Physician hours spent on billing-related work.

Because that number has a human cost.


Future outlook: the practice becomes an intelligent system

The next generation of physician-owned practices will not necessarily be defined by size.

A small practice with excellent technology and clean workflows can potentially operate with far less administrative friction than a larger organization built on disconnected systems.

The future practice may look something like this:

The patient schedules.

Eligibility is checked.

Potential authorization issues are identified.

The encounter occurs.

Relevant documentation requirements are surfaced without interrupting clinical reasoning.

The claim is prepared.

Exceptions are routed to humans.

Routine work is automated.

Payer responses are analyzed.

Recurring problems are detected.

The system learns.

The practice improves.

The physician gets more time back.

That is what useful healthcare AI should feel like.

Not magical.

Just less annoying.

And honestly, that would be a pretty impressive healthcare breakthrough.


The bigger lesson from Ericka Akoto

Ericka didn't need her healthcare team to know everything.

She needed them to notice something important.

That's the difference.

Healthcare has no shortage of information.

What it lacks is connected attention.

The same is true of revenue cycle.

We don't necessarily need another report telling us that claims are being denied.

We need to understand why.

We need to connect the dots.

And we need to act before the failure becomes expensive.

That's the opportunity.


Final Thoughts: Stop Fixing What You Could Prevent

Ericka Akoto's favorite couch had nothing to do with medical billing.

That's precisely why I like this story.

It reminds us that healthcare isn't a collection of transactions.

It's a collection of human experiences.

The physical therapist didn't need another database.

They needed to see.

The nurse didn't need another dashboard.

They needed time.

The patient didn't need another workflow.

She needed someone to understand her reality.

And physicians don't need another billing chore.

They need a system that understands the signals created by their work.

The best denial is the one that never happens.

The best administrative task is the one the system quietly removes.

And the best healthcare technology is the technology that gives clinicians more room to be clinicians.


Get Involved

So here's the question I want to leave with you:

If your practice could permanently eliminate one administrative headache tomorrow, what would you choose?

Eligibility?

Prior authorization?

Documentation?

Coding?

Denials?

A/R?

Payer calls?

Or the endless “Can you just check this one thing?” messages that somehow become a second career?

Tell me in the comments.

Your answer may reveal where the next major healthcare innovation opportunity actually is.

Share this post with a physician or clinic owner who is still spending too much time fixing problems that should have been prevented upstream.

And if you believe healthcare can be both more human and more operationally intelligent, join the conversation.


Continue the Conversation

I write about the messy intersection of medicine, healthcare operations, AI, medical billing, entrepreneurship, and the future of physician-owned practices.

The goal isn't to predict the future from a conference stage.

It's to understand what is actually happening inside practices—and figure out what should change.

Knowledge is useful. Applied knowledge is leverage.

Explore more:

Website: Dr. Daniel Cham

Podcast: Spotify

YouTube: Dr. Cham

X: @dr_cham84139

Facebook: Dr. Daniel Cham


Free Resource

There is a free resource waiting in the Featured section of my LinkedIn profile.

No complicated funnel.

No need to schedule a call.

No sales pitch disguised as a white paper.

Just something useful you can take back to your practice.

Start there if you want a practical next step.


About the Author

Dr. Daniel Cham is a physician, healthcare consultant, entrepreneur, and founder of OnnX, an AI-powered medical billing platform focused on reducing administrative friction for small and medium-sized physician-owned practices.

His work focuses on the intersection of clinical medicine, healthcare management, medical billing, AI, healthcare technology, and operational design.

His central belief is simple:

Healthcare technology should give physicians more time to practice medicine—not create another system they have to manage.

Connect with Dr. Cham on LinkedIn.


Disclaimer

This article is intended for general educational and informational purposes and should not be interpreted as medical, legal, coding, reimbursement, compliance, or financial advice.

Healthcare laws, payer requirements, contracts, coding rules, and technology regulations change. Practices should consult appropriately qualified professionals for guidance specific to their circumstances.


References

1. VCU Health — Ericka Akoto and Hospital at Home: The August 24, 2026 patient story provides the human foundation for this article, including Ericka's experience, the VCU care team, and the couch intervention.

Read the VCU Health story

2. American Hospital Association — Hospital at Home: Current AHA reporting describes the growth of hospital-at-home programs and the broader shift toward care delivered outside traditional inpatient settings.

Read the AHA analysis

3. American Hospital Association — 2026 Healthcare Demand Forecast: Current projections point toward continued growth in outpatient, virtual, and post-acute care, reinforcing the need for healthcare organizations to connect information across settings.

Read the 2026 AHA forecast


Final Three Sentences

Stop treating every denial as a billing problem.

Start looking upstream for the signal that created it.

And build healthcare technology that helps physicians see what matters before the system asks them to clean it up.


#HealthcareAI #MedicalBilling #RevenueCycleManagement #RCM #PhysicianLeadership #PhysicianOwnedPractice #IndependentPractice #HealthcareInnovation #HealthTech #MedicalPracticeManagement #DenialPrevention #HealthcareAutomation #ClinicalOperations #HealthcareEntrepreneur #PhysicianEntrepreneur #PatientCenteredCare #HealthcareTechnology #PracticeManagement #AIinHealthcare #OnnX

 

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