How the AI works
A clean claim isn’t a paid claim.
MRI brain
CPT 70551 · no contrast
Payer
AI read 47 signals
This payer denies headache-only brain MRIs without prior auth.
Our AI reads how each payer actually pays, across dozens of signals — and fixes what they’d deny before you ever send it.
The AI prepares the fix · a human owns every call
- of appealed denials,
overturned - faster to cash
the wait on our side - 3–5×
- more claims
per biller
The model
Predict, prepare, pursue — then learn from every outcome.
Four stages, one loop. AI does the work at each stage; our experienced team runs it and owns every call.
Predict
Read how this payer pays now, and score the claim before it goes out.
Prepare
Code and scrub to this payer — not to generic rules.
Pursue
Track every claim; when one stalls, our team works the payer until it pays.
Post & learn
Feed every outcome back — the next claim is shaped by what just happened.
Where claims get lost — and where our AI wins them.
The claim’s path, in three phases. We spotlight the few steps where the money is actually won or lost.
Rules encode the payer’s stated policy. Our behavior-trained AI learns what the payer actually does — including the rules they never published.
Before it goes out
PreventEligibility & benefits
Where we winStops denials before they start.
Ours reads this plan's rules and how this payer has been paying — killing dead coverage and missing auths before the visit.
Prior auth required · CPT 70551
Reads this payer’s recent behavior
Reads this plan · the #1 source of denials
Coding. AI suggests each code with the rule behind it; our team keeps the final say.
Scrubbing
Where we winA clean claim isn’t a paid claim.
Ours weighs dozens of signals — including this payer's recent behavior — and predicts whether it'll be PAID, not just clean.
A scrubber
- Codes
- Fields
- NCCI
- Format
Our signals · dozens
Dozens of signals vs a handful of rules
Out & back
TrackSubmission. AI submits the way each payer accepts — clearinghouse or portal — and catches clearinghouse rejections fast.
Remittance. AI posts and reconciles automatically, flagging underpayments against your contract.
Won or written off
FightDenials & appeals
Where we winThis is where the money is.
Ours drafts the appeal this payer actually responds to — learned from its own recent overturns.
Template
Shaped to Aetna
The appeal this payer responds to
Why our AI wins
Not a scrubber with a new coat of paint.
We didn’t invent payer-behavior billing — we sharpened it. Four reasons our model reads your payers better than off-the-shelf rules:
Trained on outcomes, not rules
It learns from real remittances — what each payer actually paid or denied — so it predicts whether a claim gets paid, not just whether it passes a scrubber.
It reads each payer
Of 5,475 codes that need prior auth across four major insurers, only 3% are required by all four — and 56% are unique to one. Ours reads each payer's recent behavior, not generic rules.
It compounds every week
Every outcome retrains it, enriched weekly across 1,000+ payers — so it gets sharper the longer we run your claims. A new biller can't start here.
A human owns the call
Our experienced team makes the judgment calls and signs off where it counts. The AI amplifies them — it never bills on its own.
What it adds up to.
Your specialty and payer mix move the exact figures.
82%
of the denials we appeal, we overturn
41%
faster to cash
the wait on our side — not payer speed
3–5×
more claims worked, per biller
~½
the cost of hand-keyed billing
A first-pass payment target of ~95% is the best-practice bar we build toward, and we read 1,000+ payers’ behavior, enriched weekly. A human signs off where it counts — nothing is auto-sent and forgotten.
Questions we get about the AI.
A scrubber checks format and codes — it proves a claim is clean. Ours weighs dozens of signals, including how each payer has actually paid claims like yours, and predicts whether it'll be PAID — then fixes it before it goes out. Clean isn't paid.
Trained on real remittances — what each payer has actually approved or denied — it reads each payer's recent behavior, not generic rules, and gets sharper every week.
No. AI does the routine; our experienced team makes the judgment calls, files appeals, and signs off. You always have a person to reach.
A human reviews anything that needs a decision before it moves, and every payment is checked against your contract. Nothing is auto-sent and forgotten.
No. AI suggests codes with the rule behind each; our certified team keeps the final say. We optimize for accuracy and getting paid, not inflating codes.
AI drafts the appeal this payer responds to, and our team works it — calls, records, follow-up — until it pays.
Yes. We work inside your existing EHR and submit the way each payer accepts (clearinghouse or portal). No migration.
Patient data lives in a HIPAA-compliant, U.S.-based environment, covered by a BAA and SOC 2 Type II — never offshored, never sold.
See it run on your own claims.
Book a short demo — we’ll show how we’d shape and fight a claim for your specialty and your payers.