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Abstract
The pitch: a neutral, venture-built clearing utility that sits between payers and providers for prior authorization, clinical evidence, claims status, and disputes, with published machine-readable rules, deterministic adjudication, and a public scoreboard. Working name Switch.
Why the market is open: the largest rails are owned by the largest payer and went dark for weeks in 2024, the second largest are owned by a consortium of plans, the third are being built by an EHR vendor for its own customers, and everyone else sells shovels for the denial war.
Why now: CMS-0057-F prior-auth process requirements generally took effect January 1, 2026, while the API requirements generally take effect January 1, 2027, for Medicare Advantage, Medicaid and CHIP programs and managed care plans, and Qualified Health Plans on federally facilitated exchanges; the AHIP pledge extends similar goals to participating commercial plans, WISeR brings algorithmic prior auth to traditional Medicare, and LLMs made chart-to-evidence extraction inexpensive, which moved the bottleneck from reading to trust.
TAM: five trillion of spend, about a trillion of admin, roughly $265 billion of administrative complexity waste, on the order of $60 billion in transaction handling, and a rails layer billing $4 to $6 billion today. Capturable software revenue of $15 to $25 billion a year, funded by the $265 billion both sides currently burn fighting each other.
Build: registry (rules, directory, eligibility) first, switch (transactions) second, clearing (netting, settlement, disputes, scoreboard) third. LLMs at the edges, determinism in the core.
Money: $300 to $400 million over five years, both-sides per-transaction pricing on a published schedule, neutrality baked into a public benefit charter with a poison pill against payer or EHR ownership, and a Visa 2008 style listing instead of a sale to a strategic.
Table of Contents
Wall Street closed on Wednesdays once, and healthcare never reopened
The company: a neutral clearing utility for the payer-provider transaction
Why the incumbents can’t build it, including the ones who could
Why now: 0057-F, the Change outage, and the agent arms race
Sizing it: a $265 billion friction pool with a $20 billion software business underneath
The product in three layers: registry, switch, clearing
LLMs at the edges, determinism in the core
Cold start: getting both sides on the rails without being owned by either
Business model, capital plan, and the Visa 2008 exit
What kills it, and the ask
