As CMS turns to AI, GenHealth.ai says it’s built for what’s next

BOSTON – GenHealth.ai believes it’s in the right place at the right time following CMS’s recent decision to use artificial intelligence (AI) to expedite the prior authorization process for traditional Medicare. 

The company, which entered the home medical equipment (HME) market earlier this year, says it leverages recent advancements in AI and large language models (LLMs), along with deep integrations into existing EMR and billing systems, to automate prior authorization submissions and streamline other administrative tasks. 

“(CMS’s WISeR model) is directing the industry to use the same technology that we’re already using,” said Ricky Sahu, CEO. “I think it’s a good signal of where the industry is going and how our approach is convergent with that.” 

The WISeR model will test whether AI-driven technologies can accelerate prior authorization for select Medicare services and items that CMS considers particularly vulnerable to fraud. The agency has issued a request for applications from companies interested in participating. 

‘We’re on both sides of the market’ 

GenHealth.ai’s roots in the payer market give it a broader and more informed perspective on prior authorization and industry trends, Sahu says. The company originally developed its solution to help payers comply with the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). Among other requirements, the rule mandates that payers implement FHIR-based APIs for prior authorizations by Jan. 1, 2027, and improve decision timeframes by Jan. 1, 2026. 

“We’re able to use a large medical model built on 140 million patients,” he said. “The way we think of ourselves is using this as a foundational layer to help automate a lot of different administrative functions, not just intake and optical character recognition (OCR) but all the clicks that you might make in an application. That’s the really big differentiator.” 

‘Think of GenHealth as your first digital team member’ 

What also makes this approach possible is GenHealth.ai’s ability to work alongside its customers, Sahu says. At his previous company, 1upHealth—which offers a FHIR data management platform for payers and health systems—and now at GenHealth.ai, he emphasizes the importance of not just integrating with customers but operating as part of their teams. 

“Think of GenHealth as your first digital team member,” he said. “We have credentials like any other team member, and we use those across systems, whether it’s email, document storage, your billing system and EMR. We interact with all of it.” 

‘It’s been neglected’ 

With margins in the HME industry so thin, AI can make a meaningful difference for providers, Sahu says. GenHealth.ai can automate up to 90% of the administrative work providers handle, resulting in significant cost savings. 

“The DME market is interesting,” he said. “It’s a place that’s been a bit neglected and it’s definitely of value to them to be able to automate a lot of these (prior authorization) decisions.”