A Case Study in DME Innovation

Scaling Patient Access with AI

This collaboration is ongoing, hence anonymized company information.

Because we configure our platform to each client’s needs, the use-case for each client can vary. Some other examples of our use-cases include:

  • Setting up the patient access program for Cooler Heads

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  • Generating appeals for an innovative sleep apnea surgery

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  • Directly helping patients overturn health insurance denials

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These are just a few potential use-cases, our tool can be used by patient access teams, providers, and/or patients. We build the platform to your specific needs.

01

Company Background

A fast-growing medical device company specializing in high-cost durable medical equipment (DME) was facing increasing pressure on its patient access operations. The company manufactures a cutting-edge device and works closely with physicians and payers to secure insurance approvals for the product. The company’s patient access team, made up of four dedicated team members, was manually reviewing patient cases to determine eligibility and write customized prior authorizations and appeals for submission to payers.

02

The Challenge

As demand for the product increased, more patient access team resources were required. Scaling headcount quickly wasn't optimal, and training on such a complex process was a challenge. Any delays risked impeding both patient access and revenue growth. As a result, the company needed a solution that could help the existing team operate more efficiently while maintaining (and hopefully improving) reliability.

"As someone who has navigated the complexities of the healthcare system for years, I can confidently say that Paxos has been a game-changer. What used to feel like a frustrating, confusing process—waiting weeks for approvals, endless calls, paperwork—has now become fast, clear, and empowering. For the first time, I felt like a real partner in my own care journey. Paxos didn’t just improve the process; they made me feel seen, heard, and respected. That means everything.
Sarah M
CEO

03

Why They Chose Paxos

Paxos offered an AI-powered software platform purpose-built for patient access teams. Because Paxos’ product was uniquely customizable, Paxos and the patient access team co-developed a solution with a clear performance benchmark: reducing case review and writing time by at least 50%, without sacrificing accuracy. The collaboration focused on two key workflows: evaluating each patient’s case to determine if sufficient information was available to support an insurance approval, and then generating customized prior authorization and appeal documents.

Our Solution

Synthesizes medical information with AI to generate prior auths, appeals, and other patient-specific documents
Transforms your team into case reviewers rather than writers by enabling AI-assisted double-checking of all outputs
Integrates payer-specific policies, diagnosis-specific guidelines, clinical literature, and product evidence
Delivers up-to-date reimbursement trend data for your device to support payer negotiations and provider sales

How Paxos Helped

Paxos built and deployed a custom software solution integrated with the company’s existing CRM. The below figure provides a high level overview of  the workflow that Paxos’ custom software automated:

To support the team’s workflow, the software incorporated several critical features, including:

01

Case Assessment

Our AI reviews the full patient file line-for-line against the exact payer policy, clinical guidelines, and product evidence in minutes, and flags missing documentation to prevent sending an incomplete submission. If a policy doesn’t exist yet, the AI can still generate a robust justification based on available clinical evidence and guidelines.

Extracted Data Analysis

Reviewers can easily verify any component of the case by clicking the citation, which displays the source document with highlighted references alongside the analysis.

02

03

Customized Justification Letter

The platform generates fully cited prior auths, appeals, and determination documents that incorporate payer language and map every statement to the criterion it satisfies, including policies and guidelines.

Intelligence and Audit Trail

Real-time analytics expose pass/fail drivers and ROI metrics, while one-click exports deliver a policy-traceable, audit-ready packet for payers, regulators, or internal QA.

04

Case Readiness Assessment
Automatically analyzes patient files against payer requirements, flags missing documentation, and provides recommendations for how to strengthen the submission.
Example of AI Summary section of Case Assessment (no real PHI)
Citations
Displays clickable citations that open the original source documents with highlighted references shown alongside the analysis, making it easy for reviewers to verify supporting evidence and ensure transparency. Internal testing showed that 100% of citations were accurate.
Example of Citation Feature (no real PHI)
Customized insurance packet
Generates customized prior authorization and appeal letters that address specific payer requirements. Automatically assembles complete insurance packets with supporting documentation to streamline submission.
  • The tool was developed with the company’s patient access team to increase the team’s productivity and reliability.
  • The software’s accurate and automated process can empower the company’s patient access team to move faster and with higher confidence. This reduces the need to scale the team as case volume grows. Work is ongoing, but initial results have validated the power of AI to transform how patient access is managed.

The software’s accuracy and automated process can help the patient access team make faster decisions with higher confidence, without needing to scale the team. Work is ongoing, but initial results have validated the power of AI to transform how patient access is managed.

Testimonials

Paxos' expertise and tailored reimbursement tools are streamlining our ability to get devices to patients, producing reliable and policy-focused documents without requiring us to hire additional staff. Their offering is also increasing utilization of our product with payers, which will help with achieving broader payer coverage.

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