Well, hi, everyone. I'm Daniel Williams, senior editor at MGMA and host of the MGMA Podcast Network. We are back with another episode of MGMA Insights, and I am so happy to share a new guest, but someone I've gotten familiar with over the last couple of weeks and had conversations with, and that's Doctor. Paula Ballester. Doctor.

Ballester is an MGMA member, also a hospitalist. She is at a freestanding children's hospital in St. Pete, Florida. And also, also is an entrepreneur and is the co founder of Easy PA. I want to make sure I get this right.

It's an AI driven platform designed to reduce friction in prior authorization and the processes there. Doctor. Ballester, you and I have talked a couple of times recently, so now we're on the podcast together. I just want to welcome you to the show.

Thank you so much. I'm excited to be here with you, Daniel.

Yeah, it's so good getting to catch up with you. We're recording this right after Thanksgiving holidays. Doctor Ballester was sharing with me her signature Thanksgiving dish, if I get this right, the cornbread dressing. Wow, that sounds so good.

Takes stuffing to the next level.

Yeah.

I can't claim it as an original recipe, but man, it always does the trick.

Yeah. That is so cool. Well, bring us up to speed then. When we have a guest on, we'd love to get to know a little bit of the background. So you are a medical doctor.

Share with us a little bit about that background and then I'll follow-up and ask you a little bit about that entrepreneurial spirit because that's a little bit different gear in the brain there. So yeah, tell us about your healthcare journey first.

I would love to. So I am a practicing pediatric hospitalist. I have been practicing now after residency for almost fifteen years. And along the way, kind of got pulled into the utilization management and the revenue cycle management space. So for the past, gosh, I think eight, nine plus years now, I have also served as medical director for utilization management at our institution and senior physician advisor.

So there I have learned kind of the other side of medicine. Of course, the clinical side still inspires me and I love pediatrics and getting to, you know, be a part of really big moments for families and helping kiddos get better. But for me, I have kind of an interesting, maybe unique is a better word, background in that prior to going to medical school, I actually worked in the insurance industry for about four to five years. And so, you know, I kind of the Venn diagram of my brain at the time kind of had this overlap where many, many, I would say the majority of physicians have no interest and really would rather do pretty much anything than deal with insurance companies and deal with kind of that piece of medicine, this very critical piece of medicine that we operate under. And so, because of my background, I was kind of tapped into this role.

And so, have really been helping our organization find better ways to do things, learning more and more daily about regulations, compliance, insurance, you know, how we can help our healthcare teams deliver care timely and efficiently. So that's my journey kind of through the past couple of decades, I guess.

Yeah. That is such an interesting background. And that's what I love learning about Guess. Because you and I talked a week or so ago, and I did not know about the insurance background. Were you an agent or on the administrative side?

Or what were you?

So believe it or not, my first job out of undergrad, I was still kind of figuring out what I wanted to do. I had gone into undergrad at the University of Michigan thinking I wanted to be a physician. Both of my parents are physicians. They never pushed me towards medicine, but I loved kids. I always knew that from the beginning.

So I really my vision entering day one into undergrad was to go to med school and be a pediatrician. Unfortunately, freshman year of undergrad was challenging and I really struggled with my intro, I think chemistry class. And I had to pull out of it and drop it because I couldn't cut it. And so that kind of made me think, Oh gosh, I can't do this. I'm not smart enough.

And I pivoted and started thinking about other careers. My degree was actually in sociology in undergrad. So, as I was trying to figure out what to do, what my next steps were, obviously, you've got to pay the bills, you know, being a grown up and finally being out of college. So I was living in Gainesville, Florida at the time and Nationwide Insurance has a big headquarters there. So, you know, I started working as a claims adjuster, believe it or not, for auto accident claims.

I kind of requested and got pulled into the medical side of the car accident claims and had served in several roles there. But that's kind of how I was able to, as I was realizing I really did want to go back to and go to medical school and I had to go back and do all my prerequisite classes while I was working full time. But that's how I was able to kind of get a little bit of exposure and experience in insurance, in medical insurance, albeit through car insurance accidents.

Yeah. I love that. What a great story. And it is unique of all the doctors I've spoken to. I don't know any were claim adjusters prior And to being a it also shows to your resilience that you stuck it out and you finally mastered chemistry, however you did it.

I don't know.

And physics and organic chemistry. Oh yeah. It was really, you know, we're all growing up at that age. I look at teenagers now and remember very fondly, but also with a lot of trepidation, kind of those years trying to figure it out on your own and being responsible and having study skills and all that stuff. But I was able to figure it out.

I'm glad that I did.

Yeah. That's wonderful. So pivoting a little bit here, you do wear that other hat, which is an entrepreneurial hat. So whether it was just having all the pajama time of spending just so many hours doing administrative work, not seeing clients or patients, or it was also part of that insurance background. Get the moment to start a business?

And tell us about that business.

Yeah. So, you know, over the years being in the role that I'm in in the hospital, I have witnessed kind of over and over and over again, docs, surgeons, you know, that are needing to perform some type of procedure, surgery, provide care for patients. You know, these are patients that are potentially suffering. They are waiting, they're anxious and watching the countless delays going back and forth between the healthcare teams trying to submit clean claims, requesting prior authorization and pre certification for services, getting denied, having to do peer to peer phone calls with the insurance company to justify why that care is medically necessary and needed. And then these back and forths, these delays watching patients suffer, watching families, you know, suffer, their parents get anxious, and the healthcare team's frustrated, right?

And so I really started to think about there has to be a better way. My initial lens was really to help my institution, which obviously I still do. But as I started kind of researching and learning about the regulatory shifts that are coming forth in the next year or two, really saw an opportunity. So I started speaking with one of my colleagues at the hospital, Doctor. Ralph Martello.

And we started brainstorming ideas of how can we make this better for practices, not just our institution, but for all practices and all healthcare teams. So we met with our third co founder, our CTO, Alex Vega, who is a genius of all things tech. And we we told him, we we said, hey, let's meet for sandwiches. So we met at a local deli and Doctor. Martello and I laid out kind of the current state.

We laid out our dream future ideal state. And we asked Alex, is this feasible? Can you build this? And he said, absolutely, without hesitation, Which kind of blew our minds because, you know, neither of us are tech folk. You know, we've both been dedicated physicians for the entirety of our careers.

Neither of us, you know, with any ventures outside of that, really. And so it was really exciting. So we started to kind of talk to local practices that we are, you know, have colleagues and friends that work in and started kind of sharing our ideas. What do you think about this? And immediately got a lot of interest and heard a lot of stories and a lot of pain points in local practices.

And that's kind of how we were born from real lived pain. And this common experience that every single practice we speak with is suffering the same problems. This is widespread. This is well known. This is not just pockets or one offs.

So we're really excited about what we're building. We've built a software platform that can help practices through the entire life cycle of prior authorization. So everything from detecting whether or not a prior authorization is even needed prior to a surgery. We've seen many practices where they have no way of knowing if a prior authorization is even needed. So they just kind of throw spaghetti against the wall and see if it sticks.

Right? Did we need it or not? They submit as a means to even verify if it's needed or not. So we can tell them if it's needed or not. We can help them strengthen the chance of authorization on first pass by by demonstrating kind of risk of denial and generating a score and showing them really practical ways, Hey, this is the wrong code.

Hey, this is the wrong You didn't support or attach the necessary documentation. You didn't include the physical therapy notes. You didn't include the MRI report. To help them strengthen that claim before they even submit it to reduce that chance of denial from the the get go. And then through all the way through, if they receive a denial, because we know denials are inevitable, we can help them generate peer to peer talking points.

So for that conversation with the insurance company or an appeal letter if needed, where we can quickly and intelligently cross reference payer policies, payer contracts, and evidence from the literature to help them more efficiently insert intelligence into the process and all the way through post bill denial. So, you perform the procedure, you got the authorization successfully, but you still got a denial on the back end. We can help you fight that too. So it's been really exciting. We're growing and developing the product every day, but that's us in a nutshell.

Yeah. That is so interesting. Now you told me, it was about a week or so ago when we talked and you told me about a particular anecdote that I think probably everybody who's a medical practice administrator or a clinician can nod their head approvingly. I think if I'm hearing it right in my head, it was the 99 email case or something like that. How refer do to it?

Yeah. So we calculated about 220 minutes of time on paperwork and administrative burden to help get one patient one procedure they needed. So there was over about a two month span, over 19 trail of emails, four 14 members of four different teams within the system having multiple phone calls, conference calls, one failed peer to peer call, one failed denial and appeal. And that was obviously, you know, pre implementation of our product, but that was one of the big drivers. And that was a really big part of our story to say like, can't be the best we can do.

Right. It didn't go through y'all's system, your program. If it had, I mean, it's just hypothetically speaking, but what would have changed? Just give us an idea because everybody who's listening is probably going, yeah, I've been through that. Yep.

We did that.

What would So I think Yeah. Yeah. I think, you know, the big difference is is that, you know, we have such a mismatch of expertise in this realm of healthcare. We have physicians who are the experts in clinical care. They know the guidelines, they know the treatments that are needed.

And then they say, We need X procedure. And then they hand that off to their team, right? Whether that's an office administrator or someone in their practice that is tasked with performing these functions, they submit the claims. And like we talked about before, they don't have expertise or knowledge of healthcare policies, policy bulletin contracts. Even the most experienced practice manager that's been doing it for thirty years cannot possibly keep pace with the number of insurance policies, the differences in contracts, the constant updates and payer requirements.

And so this is where we saw the biggest mismatch because we have no role in healthcare where anyone can possibly have the amount of knowledge needed to quickly and efficiently process these prior authorizations and appeals. So that's why we built this is the perfect use case for AI and for automation because we can quickly, efficiently, and intelligently look at the clinic's own insurance contract with the payer, with other policy bulletins and other policies that are published by the payers, and quickly say, Hey, for this procedure, you need to show X, Y, and Z, rather than just guessing, right? Because that's what folks and teens are doing right now is they're doing their best guess based on their experience. And a lot of times, if they're doing the same types of cases over and over, right, they can get good at it because they realize from, you know, past trial and error, right, what they need to do next time. But I think our product really helps them do it right from the beginning.

Reducing denials because you've got a clean claim from the beginning is one of the most effective ways to improve your operations and, you know, reduce revenue lead too, only notwithstanding the most important thing is get your patients quicker access to care.

You had sent me some information and we spoke a week ago and you were telling me you've worked with some practices trying to modernize the way that they address this. How do those conversations go? Give us a little insight into the conversation, the kind of questions or pain points that the practices are sharing with you, and how you're helping them see it with new eyes through a new lens with this new technology and the new platform.

And it's such an important question because I think right now there is, you know, we're in the AI boom. We're trying to figure out in healthcare how the heck do we do this responsibly? How do we do it securely? How do we not compromise patient data? And, you know, there are so many shiny toys out there.

It's like, well, what's noise? What can really help my practice? So I think for us, our advantage is we're physician built. So we started from knowing the pain and experiencing it, knowing the frustrations, knowing the workflows firsthand. And so that gives us an automatic advantage because we are, you know, as they say in lean, right?

We're at the Gimba. We don't have to go there because we're already there. So we understand what's happening. So when we've been speaking with practices that are piloting our product, it's been great because they've fantastic partners, so supportive, giving us real feedback. Hey, this part of the interface would be easier if you could do X, Y, or Z.

So not only making it more streamlined so that it's more user friendly because we don't want to introduce friction, right? And the whole goal of our product is to reduce friction. So hearing that feedback to refine the product has been super important. But really, it's just been that relief almost that we are hearing from the practices that we're delivering what what our goal is, right, is to make it easier, make it faster, and really to help the teams feel more confident in what they're doing rather than guessing. Mhmm.

You brought up a great point, one that I'm challenging myself with. There are so many new shiny toys out there right now, And it is overwhelming. And that's one thing at MGMA we're attempting to do is to provide a platform where our members can go and we'll provide them with some guidance on what's real, and not even what's real, but what fits what their needs are. So putting your clinician hat on and your administrative hat on from that side of it, because you're probably being inundated with other AI tools and other technology tools. What are some processes that an administrator or clinician can go through to figure out what really is the right choice?

Because there are so many choices out there and you don't want to spend so much time picking the wrong one. How would you address that? Not looking at it from the easy PA side, but from the administrator side.

Sure. I think data is the most important thing. Right? You have to understand your own data before you can identify your opportunities for improvement. So, you know, we have spoken with a lot of practices now.

And I think one of the things that is most surprising to me and is also a struggle in my own institution is that we don't have good data. So you if you ask practices, what is your first pass authorization success rate? How many claims do you currently have pending? How many claims you are you late you know, do you need to follow-up on? How many dollars are at issue?

What is your average time to submit and get authorization? Blank stares. And it's really hard because there's not a lot of support out there to help practices tell that story and to understand their opportunities. And when you look at it from from an administrative and executive perspective, you know, there are opportunities such as gold carding with insurance companies where if you're able to demonstrate that you have a really high success rate with your claims and with your appeals, and you can demonstrate that, then you can get kind of, you know, a gold card where you'll get to kind of bypass some of the processes because you've kind of been vetted and shown that you're what you're doing is right. And clinics don't even have a way to show that because they they're not tracking the data.

So I think first and foremost is you have to have data. Obviously, going back to wearing my entrepreneur hat, that was one of the biggest things we decided we had to build for the clinic so that they would be able to understand their pain points and understand trends. What payers are causing the most problems? What codes are causing the most problems? Where are we losing the most revenue?

And things like that. So we have built all of that out very intentionally to arm clinics with really understanding their own opportunities. So I think those are, that's probably the biggest part for me is really understanding your own data and your own process. We've spoken with many clinics where, you know, if you're speaking with physician leadership, for example, they don't even know their process. They just know they request something and then magic happens.

Their team makes the magic happen. They don't they may not even know about the hours and the frustration and the portal popping and the faxes and the phone calls because that magic is done by other members of their team. And so, you know, it's really getting at the Gemba, right, and understanding what your team's pain points are. And it's really hard to do that without data.

Yeah, it is. For anybody who doesn't know what Gimba is, just to define what is Gimba for any of our listeners who might be trying to type it in right now to figure out what that is. No.

In in lean methodology, when you're really learning how to improve practice, you know, practices and and processes and operations. Getting to the Gemba means you've got to go to where the action is happening, where that process is happening. You've got to understand every touch point, every piece of the process. You can't just know the start and the end. You've got to know where does that claim go?

Who's the one that's initially making that request? How do they do it? Where do they do it? How much time does it take? What's the next step when they hear back?

How do they log that or enter it? What system is tracking it and really mapping out and really understanding it. You have to understand all of those pieces to really understand your opportunities for improving the process.

Okay. Before we switch gears, I have a couple of questions that aren't related to prior authorization.

But before

we switch gears, is there anything I didn't ask you about prior auth or about EasyPA that you wanted to share with us about that?

Yeah. I think the big thing is for any, you know, any healthcare leaders, clinic, you know, executives who are listening, I think there is a lot of regulatory changes coming. And so this to me is the perfect time for kind of digital transformations in healthcare because for 30+ years, it's been the same thing. We've been doing things the same way. There's been no modernization at all.

But now the Center for Medicare and Medicaid Services, if you look up 0057- F, they are requiring that there is increased transparency and proved processes in the prior authorization space specifically. So by 01/01/2027, all insurance companies are going to be required to be able to transmit prior authorizations electronically, which is going to be a huge shift. They're going to have to turn those non urgent requests around in seven days, whereas now it's at least fourteen days for most routine requests. And there has to be improved transparency and visibility. So I think the great thing for us in healthcare right now is we finally have regulatory pressure forcing change in this really archaic space.

So it's a beautiful time and opportunity for practices to leverage that and to improve their own processes so that they can benefit from that, right? If your practice is still faxing and portal hopping, once the insurance companies are required to do these electronic transmissions, you're really missing out on an opportunity to decrease that turnaround time for your patients and to improve that process for your staff. So I think that's another thing that I would encourage, leaders out there listening to look into and to really come up with a plan for how they're going to leverage that for their own practice, because we know that less than 0.5% of practices are ready today.

Wow. Okay. So switching gears.

Yes.

We did talk about something really interesting. I think this can be helpful to our women listeners. You talked about how a lot of times in very high level meetings that you're in in health care, in the entrepreneurial setting, you have found yourself often the only woman in some of these meetings. But you have had an incredibly successful career. So what advice can you give to our women listeners today in how they navigate that space, how they succeed in healthcare, succeed in the entrepreneurial world?

What have you leaned into to find that success?

Oh, that's such a great question and probably a topic of for an entire series of Right? But I think, you know, every person should define their own success individually. And I think, you know, for women that want to and are in leadership roles is to own their confidence, own their courage, own their expertise. And I think to not shy away from opportunities, not shy away from challenges. We deserve to be in the spaces just as much as anyone else.

I think a lot of times women, particularly and more so than men, have imposter imposter syndrome and kind of worry that they're not qualified, that they're not deserving of those opportunities. We know that there are inherent systemic barriers as well. And so I just challenge women to believe in themselves first and not to shy away from, you know, representing themselves, demanding their worth and their value and showing up in those spaces and showing, you know, what we can do. From everything on the clinical side, we know that many studies have shown better outcomes with female physicians, surgeons, and we are increasingly taking up and expanding in our leadership capabilities and roles. And so own that and be a part of that and tell your story.

It's been an interesting journey so far, and and I'm excited to kind of help represent that for other women.

Yeah. Last question. Because I really do like to get to know the guest outside of the work they do. So you were sharing with me that you are an enthusiastic basketball mom, and I'm a I'm a former cheer dad. My daughter Nice.

Was a cheerleader both in high school and college. And so I was cheering along with her, and we just met at Thanksgiving and went So through some of the cheers together what has that experience been like where you can really focus on the kids and watching them play basketball, maybe show them how to make a good two handed bounce pass, that sort of thing. But what what has that been like?

So I am the proud mom to an almost 13 year old son named MJ, and he is an avid basketball player. This is the first year that he's been able to play for his middle school team, which has been so much fun. He's also been involved in many rec leagues and AAU teams. So, you know, I think even going back to your previous question, right, is how do we do it all? And I think it's you have to have your firm boundaries.

What is important to you? What is non negotiable? And how do you make everything else work around it? And I think to me, the biggest parts of my success I attribute to, you know, having community and that's chosen family and community, my girlfriends, my family that are all so incredibly supportive and cheer for me every step of the way. But also my son because he's my motivation.

He's why I do everything that I do. He's why I've chosen the role that I've chosen because to me personally, it was really important that I can go to those basketball games and I can go to his tournaments. And yeah, of course, I miss a few every now and then. I have to work weekends. I have to work night shifts, But I do my best to prioritize scheduling my clinical shifts and my meetings in times that won't conflict with me being able to be his number one fan.

So, I am one of those loud moms in the stands. I'm cheering. I have an amazing group of basketball moms that we've all become close and friends with, and we love, you know, cheering our boys on together. So those are the things that fill my cup and bring me a lot of joy outside of the daily kind of grind of medical practice and entrepreneurial life. Those are the things that keep me centered and grounded and really bring me a lot of joy.

That is so cool. Well, Doctor. Paula Ballester, a hospitalist and an entrepreneur or founder of EasyPA, thanks for joining us today.

Absolutely. It was a pleasure. I really appreciate you.

Yeah. Everybody listening, we're going to put a lot of information in the episode show notes. We might even put Doctor. Ballester's recipes from Thanksgiving, if we're lucky. Who knows?

But I just want to say, thank you all for being MGMA podcast listeners.