// Built for the Health Plan Ecosystem

Workflow Economics
for Clinical Operations

What if the granularity of operational control, one case at a time, met the rigor of financial planning and cost control, from the model to the monthly variance?

Book a Call Connect Work to Cost

// Live, not quarterly

Run Clinical Operations on One Ledger

Priced, controlled, and proven, case by case

Today the cost lives in a quarterly allocation, the work lives in the queue, and the AI claim lives on a vendor slide. None of them can tell a clean case from a messy one.

250,000 cases this month · time to close × cost per case
Time to close from 0h to 96h, with the 72h SLA marked; cost per case from $0 to $80, with the $40 target marked.
Clean, on time and on target ($40 or less, 72h or less): 79%, 198,500 cases
On time, over target (more than $40, 72h or less): 12%, 29,000 cases
Late, on target ($40 or less, more than 72h): 8%, 19,200 cases
Messy, late and over (more than $40, more than 72h): 1%, 3,300 cases
Highlighted: Case 4817305 · 63h · $47.52, +$7.52 over target, on time.

Workflow Economics

What does a case cost, and what should it?

Cost per case is total spend divided by volume, refreshed quarterly. It cannot say what a second clinical review costs, which step is over its share, or what the new AI vendor actually saved.

Explore Workflow Economics

Operational Control

Where does work go and where does it stall?

Your reports tell you about breaches weeks after they happened. Cases cross 10+ stages, most of the clock burns in queue wait, not review, and you can't see that today.

Explore live case flow

AI Adoption & ROI

Is AI actually changing ops or just generating output?

Vendors report lift, boards want proof, state AI laws now require it. Most teams see model output, not whether the operation downstream actually improved.

Explore AI impact

// Platform Overview

Model It. Control It. Prove It.

Three lenses on the same recorded work. Operations runs the queue on it; finance prices it; both read one ledger.

Workflow Economics

Price the work. Set the target. Control the gap.

Give each kind of recorded fact one price: a case exists, it visits a step, an exception happens, automation does the work. Every case then prices itself from its own history. Set a cost-per-case target, give each step its share, and read the gap by step, by action and by case, every month.

ModelA price list, not a time study. Reprice the same history under a vendor rate or an AI-first design.
TargetOne figure per case, a share per step, a date. The step owner gets a number for their step.
ControlMonth → cohort → case. Every count opens the cases behind it; every case opens its ledger.

Model

Cost model · Current Process Model

One-pass cost with Extra and Saving effects on a shared $0–$40 scale.

Base cost per case: $6.00
+ Standard visit costs · 4 States: +$21.00
= One-pass cost: $27.00
+ all Extra effects · 3 rules: +$9.00
− all Saving effects · 3 rules: −$7.00
Unreviewed · 2 rules: unpriced

One-pass cost with all Savings / all Extras: $20.00 – $36.00

Configuration only: one visit per state, each rule at most once. Not a forecast; replay results live in Financial Performance.

Target vs modeled

Goal vs modeled result

Two aligned compositions on one scale. Goal State Targets + Unallocated Target = $30.00; modeled State contributions + Base Cost per Case = $31.50.

Operational Goal · targets$30.00 per case

Intake$5.00

Clinical Review$15.00

Decision$4.00

Unallocated$6.00

$30.00

Current Process Model · modeledreconciles to $31.50

Intake$4.20

Clinical Review$16.40

Decision$2.90

Notif$2.00

Base Cost$6.00

$31.50

Explore Workflow Economics

Operational Control

See where every case stands, and who has it, right now

Live heatmap of every case across every stage. Know which SLAs are about to breach, where rework loops concentrate, and which queues need intervention. Every resource ranked by throughput, handle time and cost, internal teams, vendors and AI side by side.

Control TowerSLA ExposureResource LeaderboardLoop Atlas

Control Tower Operational Flow heatmap — Operon.Cloud Control Tower. Example workflow data.

Explore Operational Control

AI Adoption & ROI

Prove what AI changed, in the same ledger

88% of health plans use AI in at least one workflow. ~5% can prove it's delivering value. Operon prices AI-touched cases with the same cost model as the humans and vendors around them, so the business case is a line in the ledger, not a slide from the vendor.

ROI Impact ExplorerAI vs. Human ComparisonAdoption Map

ROI Impact Explorer showing AI adoption metrics and cost savings — Operon.Cloud ROI Impact Explorer. Example workflow data.

Explore AI Adoption & ROI

// Queue to case

The ops lead's queue, case by case, before the SLA hits.

Every case in flight, across every stage, team, vendor and AI step. Where the calendar time burns, where work repeats, and which cases are predicted to miss their SLA next, while there is still time to move them. Every count opens the cases behind it; every resource, delegate and AI actor ranks on the same columns.

Cases: 44,200; total · 9,900 active · PA workstream · 10 states · 1,240 resources
Effective SLA p90: 4d 18h; most of it dwell time, not active review
Within SLA · active cases: 78%; 2,200 already exceeded · 1,000 at risk now
Prediction AI risk: 4,900; predicted to miss SLA · 3,900 high · 1,000 medium
Repeat touches: 107%; touches per case beyond the first · 44% of all touches AI-assisted

Illustrative data · Operational snapshot · Loop Atlas uses a separate 100,000-case sample

Risk AI

Predictive Risk AI

Where active work is most likely to miss SLA next, so action can happen earlier. Color intensity highlights where attention is needed most.

Illustrative

Total

Draft

Intake

Routing / Triage

Pend / Awaiting Documentation

Clinical Review (RN)

Medical Director Review (MD)

Peer-to-Peer / Provider Discussion

Decision / Finalize

Correspondence

Closed

Current state

44,200

400

900

1,300

700

3,500

200

400

2,000

500

34,300

Medium Risk SLA Failure Prediction

1,000

100

400

200

300

High Risk SLA Failure Prediction

3,900

100

600

1,400

200

1,100

300

Dwell time

4d 18h

2h 41m

7h 4m

12h 24m

1d 13h

22h 35m

1d 3h

20h 20m

14h 54m

4h 13m

Heat scaled within each row. Total column is the workstream.

Clinical Review: 1,400 high-risk of 3,500 in state · Explore SLA risk

Control Tower

Time & Touch Hotspots

Where calendar time is spent vs where interactions concentrate, for the selected workstream and window.

p90p95p99

Pend / Awaiting DocumentationFriction hotspot

Calendar time2d 15h

Touches / case3.1

6,400 cases19,600 touches

Medical Director Review (MD)Friction hotspot

Calendar time1d 21h

Touches / case3.8

4,400 cases16,700 touches

Clinical Review (RN)Friction hotspot

Calendar time1d 15h

Touches / case3.5

30,000 cases105,900 touches

Routing / TriageHealthy

Calendar time22h 36m

Touches / case1.7

28,700 cases49,000 touches

IntakeHealthy

Calendar time11h 49m

Touches / case1.7

32,300 cases54,800 touches

CorrespondenceHealthy

Calendar time7h 31m

Touches / case1.7

31,300 cases52,600 touches

Calendar time (p90)Touches per case

Loop Atlas

Rework loops by interaction

Which interactions repeat inside a case, how often, and what the repeats cost at the model's per-repetition price.

100,000 cases

Loop rate92.2%92,200 cases with loops

Repetitions8.7709,100 occurrences

Time burden22,600 hrsextra time from rework

Cost burden$1.36Mextra cost from rework

InteractionOccurr.Loop rateRepsBurden

PA Auto-Approval Decision91,70099.3%4.0$48K

PA Finalization and Correspondence91,60064.4%2.4$186K

PA Auto-Workflow Routing82,20063.4%2.6$22K

PA AI Assisted Clinical Review60,30052.1%2.7$348K

PA Medical Director Review60,10051.2%2.6$756K

Burden is priced from the cost model; the same repeats show up in cost per case below. Repeats are recorded facts, not automatically waste.

Every one of these cases already carries its price

The same recorded visits and touches that put a case on these screens are what Workflow Economics prices below. Move a case today; see what it cost at month end.

// Budget to case · Same record

The CFO's number, priced from the operations record.

Budget vs actual by the month the work started, modeled cost against last year’s baseline and this year’s target, with every dollar traceable to a workflow step and an action. Every count opens the cases behind it; every case opens its ledger.

Total modeled cost: $60.5M; 1.64M Cases · Jan – Aug 2026
Cost per Case: $36.90; $39.40 in Jan → $34.40 in Aug
Cases by first touch: 1.64M; 196k in Jan → 208k in Aug
Implied budget · Operational Goal: $52.5M; $32.00 × 1.64M · over by +$8.0M
Effort in window: $57.9M; work dated Jan – Aug · $2.6M of first-touch cost falls after Aug

Illustrative figures · Monthly detail: Mar–Aug 2026

Cases by first touch · full modeled cost

Each Case booked whole to its first-touch month, beside the budget the target implies.

Modeled cost of Cases startedImplied budget · $32.00 × Cases

Cost per Case by first-touch month

Modeled cost against last year’s baseline and the targets you set.

Current Process ModelHistoricalGoals

Improvement $6.80 · Gap +$2.40 · Progress 74% · Explore the worked example

Explore Workflow Economics Explore Operational Control Explore AI Adoption & ROI

// Blind spots

How These Blind Spots Play Out
Across Your Organization

Cost precision, process control, AI proof. The same three gaps show up in every leadership meeting, but hit each role differently.

Who's askingWorkflow EconomicsOperational ControlAI Adoption & ROI

Finance & MeasurementCFO, VP Finance, VP Performance Measurement

Workflow Economics

Cost per case is an average, not an account

Total spend divided by volume, refreshed quarterly. No cost per touch, per rework loop, or per step. The $2 improvement cannot be attributed, so it cannot be defended.

Operational Control

Rework loops are invisible cost drivers

Cases loop 2-3x through the same stages. Nobody quantifies the cost of each loop or the margin it consumes.

AI Adoption & ROI

AI spend has no measurable return

Millions allocated to AI vendors. Budget reviews ask for ROI numbers. All finance has is vendor-reported "efficiency gains."

Clinical LeadershipCMO, VP Clinical Ops, VP Quality

Workflow Economics

The step owner has no number for their step

Targets are set per program, per year. Clinical Review has no share of the target and no way to see its contribution to the gap.

Operational Control

SLA breaches surface after the damage is done

Cases cross 10+ stages. Failures show up in monthly reports, weeks too late. No live view of which cases are at risk right now.

AI Adoption & ROI

AI touches cases but clinical impact is unclear

Told AI reduces turnaround. Can't verify from clinical workflow data. No audit trail for AI-driven decisions.

Operations & Vendor MgmtCOO, VP Vendor Management, VP Transformation

Workflow Economics

A vendor rate card cannot be tested before signing

No way to reprice last year's cases under the proposed rate and compare it to today's staffing on the same work.

Operational Control

Operating model is a black box

1,200+ resources, 3 vendors, AI. No unified view of who performs, who underperforms, or that 60% of cases are unassigned.

AI Adoption & ROI

Can't baseline before vs. after AI

Transformation projects need before/after proof. Without operational baselines, there's no way to measure what AI changed.

IT, Digital & InnovationCIO, CTO, Chief AI Officer, VP Digital Transformation

Workflow Economics

Human vs. AI cost comparison doesn't exist

Can't compare what a case costs when handled by AI vs. human vs. hybrid on one price list. No data to optimize the mix.

Operational Control

No workflow-level data for AI to learn from

AI metrics live in vendor dashboards. Not tied to actual case outcomes, stages, or process context.

AI Adoption & ROI

Can't prove AI ROI to the board

AI deployed across 4+ workflows. Board asks for numbers. All you have is "we think it's helping."

Explore Workflow Economics Explore Operational Control Explore AI Adoption & ROI

// Use Cases

Where Health Plans Feel It Most

Prior Authorization Economics

Price every PA case from its own history: intake, clinical review, MD review, decision. Set the cost-per-case target, give each step its share, and see which step is over it this month.

Learn more

Vendor Performance Scorecarding

Hold every delegate accountable with data. Independent, case-level performance and cost for every vendor resource, on the same price list as your own teams.

Learn more

Claims Exception Cost

See what happens after the happy path ends. Fall-out, pend aging, denial-rework loops, and the true cost of every exception your auto-adj engine misses.

Learn more

AI Business Case & Proof

Model the AI vendor's claim against last year's cases before you sign; then read the actual saving per case in the same ledger once it is live.

Learn more

Quality & Stars Visibility

Connect clinical execution to HEDIS and Stars outcomes in real time. See whether UM, CM, and care-gap interventions are actually moving the measures that quality leaders own.

Learn more

Pharmacy PA Visibility

Stop managing specialty drug queues from a spreadsheet. Real-time visibility into every pharmacy PA, segmented by drug class, SLA risk, decision stage and cost.

Learn more

// Next Step

Let's See If We Can Help

No pitch deck. No pressure. Just a conversation about what you're trying to solve and whether we're a fit.

Good fit if you're

Trying to answer 'what does a case cost?' without a 3-week spreadsheet

Setting a cost target and needing each step owner to carry a share of it

Running clinical workflows and finding out about SLA breaches weeks after they happen

Running AI in production but can't prove the ROI

Workflow Economicsfor Clinical Operations

Run Clinical Operations on One Ledger

What does a case cost, and what should it?

Where does work go and where does it stall?

Is AI actually changing ops or just generating output?

Model It. Control It. Prove It.

Workflow Economics

Cost model · Current Process Model

Goal vs modeled result

Operational Control

AI Adoption & ROI

The ops lead's queue, case by case, before the SLA hits.

Predictive Risk AI

Time & Touch Hotspots

Rework loops by interaction

The CFO's number, priced from the operations record.

Cases by first touch · full modeled cost

Cost per Case by first-touch month

How These Blind Spots Play OutAcross Your Organization

Where Health Plans Feel It Most

Prior Authorization Economics

Vendor Performance Scorecarding

Claims Exception Cost

AI Business Case & Proof

Quality & Stars Visibility

Pharmacy PA Visibility

Let's See If We Can Help

Workflow Economics
for Clinical Operations

How These Blind Spots Play Out
Across Your Organization