Denial Management Agent: Recover Lost Revenue
Identifies denied claims, determines root cause, corrects errors, resubmits claims, and appeals when appropriate—all automatically.
Key Capabilities
- Denial Detection - Monitors 835 remittance advice for denials and underpayments
- Root Cause Analysis - Categorizes denials (coding error, missing info, medical necessity)
- Auto-Correction - Fixes simple errors (wrong modifier, missing diagnosis) and resubmits
- Appeal Generation - Creates appeal letters with clinical rationale for medical necessity
- Trend Analysis - Identifies patterns (e.g., Payer X always denies Code Y)
- Recovery Tracking - Monitors resubmissions and appeals to closure
- Performance Metrics - Dashboards showing denial rates and recovery rates
- Payer Pattern Learning - AI learns payer-specific denial patterns
Impact
Recovery Rate
+30-50%
Days in A/R
-15-20 days
Write-Offs
-20-30%
Cash Flow
Improved
Technical Details
Integration & Features
- EDI Processing
- 835 remittance advice parsing and analysis
- Integration
- Clearinghouse and payer portals
- ML Models
- Machine learning for denial prediction
- Reporting
- Real-time denial trend dashboards
Security & Compliance
- HIPAA Compliant
- SOC 2 Type II Certified
- Real-time processing and logging
- End-to-end encryption
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