Denial categorisation
Coding, eligibility, authorization, timely filing, medical necessity, duplicate and coordination-of-benefits — each with its own playbook.
11 · Revenue cycle
AI Denials & Appeals Agent
Denials are not a billing problem, they are a process problem with a deadline. The agent works them continuously, drafts the appeals, and tells you which upstream failure keeps producing them.
Agent at a glance
- StatusIn development
- CategoryRevenue cycle
- Deployment2–4 weeks, shadow mode first
- Review modelHuman approval per action, configurable
- Headline metric< 7 days To work
- EvidenceFull action log, exportable any time
< 7 days
Denial worked
From receipt to appeal or correction, inside the appeal window.
40–60%
Appeal overturn rate
Typical where appeals carry the right clinical documentation.
30%
Denial reduction
Within two quarters once root causes are fixed upstream.
What it does
Everything in this agent, in writing.
Appeal drafting
Payer-specific appeal letters citing the policy, the clinical evidence and the coding rationale, ready for review and signature.
Corrected claim resubmission
Where an appeal is the wrong instrument, the claim is corrected and refiled with the fix documented.
Underpayment detection
Paid claims compared against the contracted rate, with variances flagged and pursued.
Root-cause reporting
The three upstream failures producing most of your denials, quantified in dollars, every month.
Payer pattern intelligence
Denial reasons tracked by payer and service line so your negotiations and contracting have data behind them.
Deployment
Live in weeks, not quarters.
01
Denial baseline
Twelve months of denials categorised and priced so you know what the problem actually costs.
02
Playbook build
An approach per denial category and payer, agreed with your team.
03
Continuous work-down
Daily categorisation, appeal drafting and resubmission with human review of every appeal before it is sent.
04
Upstream fixing
Monthly root-cause review with your clinical and front-desk leads.
Guardrails
What it will never do.
These limits hold regardless of configuration. They exist so that you can put an agent in front of patients without putting your licence next to it.
- Appeals state only what the record supports — no inflated clinical claims
- Every appeal is reviewed and signed by a human before submission
- Timely-filing deadlines tracked, with escalation at 30/15/5 days remaining
- Write-offs require human approval against your policy — the agent cannot forgive a balance
- Full correspondence trail retained per claim for audit and for payer disputes
Human in the loop, by your choice
Every action can require approval before it commits. Start with all of denials agent queued to your staff or to ours, watch the accuracy numbers, then widen autonomy workflow by workflow — or leave it queued forever. Both are supported.
Escalations land with certified people
Our review queue is staffed by the same certified coders, billers and credentialing specialists who run our managed services. Not a support desk, and not a chatbot watching a chatbot.
Full evidence trail
Input, decision, action, confidence, model version, reviewer and timestamp — retained and exportable as CSV or JSON, including after you leave us.
What we report against
Operational targets for this agent. They are internal commitments measured on your own data, reported monthly — including the misses.
< 7 days
To work
40–60%
Overturn rate
30%
Fewer denials
100%
Human-signed appeals
Works with your systems
Your EMR, your numbers, your data.
- Availity
- Change Healthcare
- Waystar
- Clearinghouse denial feeds
- Athena
- eClinicalWorks
- NextGen
We integrate through FHIR and HL7 where the vendor supports it, and through secure automation or structured document intake where it does not. No API required, no vendor commission taken.
FAQ
Common questions.
How is this different from a denial worklist?
A worklist tells you what is denied. This categorises it, decides the right action, drafts the appeal, pulls the supporting documentation, tracks the deadline and reports the pattern. Your team reviews and signs.
Do the appeals actually win?
Overturn rates in the 40–60% range are typical when the appeal cites the payer's own policy alongside the clinical record. Appeals without clinical support overturn far less often — which is the point of assembling the packet properly.
What about timely filing?
Every denial carries its remaining window and escalates at 30, 15 and 5 days. Timely-filing write-offs are almost entirely a capacity problem, and capacity is what this fixes.
Will it argue with payers on the phone?
It handles the administrative portion of payer calls and escalates to a human for clinical or contractual disputes. Where a payer requires a clinician, we route it and prepare the brief.
Related agents
Usually deployed together.
12
In development
AI Payment Posting Agent
Reads ERAs and EOBs, matches payments to claims, posts insurance and patient amounts, verifies contractual adjustments, and reconciles every posting against the bank deposit.
- ERA and EOB posting with line-level matching
- Contractual adjustments verified, underpayments flagged
- Daily reconciliation to bank deposits with exceptions queued
13
In development
AI Credentialing Agent
Keeps every provider's credentials, CAQH profile, payer enrolment and expirables current — prefilling applications, chasing payers and escalating before anything lapses.
- Applications prefilled from a single source-of-truth profile
- Payer follow-up on a fixed cadence with escalation paths
- Expirables tracked with 120/90/60/30-day escalation
01
In development
AI Phone Agent
Answers every call on your existing number, day or night. Books and moves appointments in your EMR, captures refill requests, answers routine questions from your own practice information, and leaves staff a transcript plus a task.
- 24/7 answering on the number patients already call
- Books, reschedules and cancels directly in your EMR
- Transcript, intent and task attached to the patient record
See it run on your own workflow.
A 30-minute demo using your scenarios, your payer mix and your systems. We will show you the guardrails and the audit log, not just the happy path.
A 30-minute call with an operations lead. No obligation, no sales sequence, and we will say so if you do not need us.