Agentic AI for revenue cycle managementagentic AI
Healthcare providers lose 3-5% of net revenue to denials, write-offs, and rework. Our agents work eligibility, coding, claims, and denials end to end — inside your perimeter, under your payer rules, with every step on the record.
- Eligibility & prior-auth verification
- Autonomous coding & charge capture
- Denial triage, appeal & resubmission
- HIPAA-aligned, fully auditable
RCM is a compliance problem wearing a billing costume
Every dollar moves through a gauntlet of rules — and every misstep is a liability.
A single encounter passes through eligibility checks, medical-necessity rules, CPT/ICD-10 coding, NCCI edits, payer-specific policies, and timely-filing windows before it ever becomes revenue. Get any layer wrong and the claim denies, the appeal clock starts, and the cost to recover often exceeds the margin on the visit.
The work is high-volume, rules-dense, and unforgiving — exactly the shape that breaks human teams and exactly where naive automation creates compliance exposure. PHI is in play on every record, so HIPAA, the minimum-necessary standard, and your BAAs govern everything an automated system is allowed to see and do.
Automatic.co builds agents that operate inside that gauntlet rather than around it: they read the same payer policies and code sets your coders do, act only within the autonomy you grant, and leave an audit trail a payer — or an auditor — can follow.
Where agents earn their keep
Each one is a discrete, governed workflow you can stand up on its own and measure.
Eligibility & prior auth
Agents verify coverage, benefits, and auth requirements against payer portals and 270/271 transactions before the visit, flagging gaps while they're still fixable.
Autonomous coding & charge capture
Agents draft CPT/ICD-10/HCPCS codes from clinical documentation, run NCCI and modifier edits, and route anything below confidence to a coder with reasoning attached.
Claim scrubbing & submission
Pre-submission scrubbing against payer-specific edits and your fee schedules catches errors before the clearinghouse does — clean claims auto-submit, the rest queue for review.
Denial triage & appeals
Agents classify denials by CARC/RARC code, pull the supporting documentation, draft the appeal, and resubmit within the filing window — escalating the gray-area cases.
Payment posting & reconciliation
ERA/835 remittances are parsed, matched, and posted; underpayments versus contracted rates are flagged for follow-up instead of quietly written off.
Patient billing & inquiries
Agents generate plain-language statements, answer balance and coverage questions, and set up payment plans — handing off to staff the moment a dispute needs judgment.
From one workflow to a governed RCM fleet
We start where the rework is most expensive and expand as trust compounds.
Map
We instrument your denial categories, aging buckets, and rework costs to find the highest-leverage workflow to automate first.
Encode the rules
Payer policies, code sets, fee schedules, and your edit logic go into a retrieval layer the agents read at runtime.
Deploy with gates
Agents ship into your VPC behind your BAA, with autonomy thresholds and human checkpoints you control.
Expand
As clean-claim and recovery rates climb, we add adjacent workflows — eligibility, posting, patient billing — to the fleet.
PHI stays inside your perimeter
RCM automation lives and dies on data handling. We deploy agents into your VPC, your hardware, or a fully isolated network so PHI never touches a third-party model endpoint. We sign a BAA before a single record moves, and every agent operates under a minimum-necessary scope.
The autonomy line is yours to draw. High-confidence, low-dollar claims can move on their own; high-charge encounters, unbundling risk, and ambiguous denials route to a human with the agent's full reasoning. Every read, edit, and submission is captured as decision lineage you can hand to an auditor or a payer.
- VPC, on-prem, or air-gapped — no PHI to third parties
- BAA-backed, minimum-necessary access scopes
- Approval gates on high-dollar and high-risk claims
- Full decision lineage for payer audits and appeals
Bots vs. agents in the revenue cycle
Why scripted RPA stalls where agents keep working.
| Legacy RPA bot | An Automatic.co agent | |
|---|---|---|
| Payer rules | Hard-coded, breaks on portal changes | Reads policies at runtime, adapts |
| Denials | Re-queues for staff | Classifies, drafts appeal, resubmits |
| Coding edge cases | Fails or forces manual entry | Flags with reasoning, routes to coder |
| Compliance | Opaque screen-scraping | Scoped access + full decision lineage |
| Maintenance | Dev ticket per rule change | Content update to the retrieval layer |
Frequently asked questions
How do agents stay HIPAA-compliant when they touch PHI?
Agents run inside your VPC or on-prem behind your BAA-covered perimeter — PHI never leaves your environment. Every read, action, and payer submission is logged with a minimum-necessary scope, and we sign a BAA before any data flows.
Will agents auto-submit claims, or do coders stay in the loop?
You set the autonomy line. Clean, high-confidence claims under your dollar threshold can auto-submit; anything ambiguous — unbundling risk, modifier conflicts, high-charge encounters — routes to a coder with the agent's reasoning attached.
Can agents keep up with changing payer rules and code sets?
Yes. Payer policies, LCD/NCD edits, CPT/ICD-10 updates, and your fee schedules live in a retrieval layer the agents read at runtime, so a rule change is a content update — not a model retrain or a quarter-long dev cycle.
How fast can we see ROI on a single workflow?
Most providers start with denial triage or eligibility verification, where the volume and rework cost are highest. A scoped agent for one of those typically lands in production in weeks and pays for itself in recovered claims and reclaimed FTE hours.
Related industries & capabilities
RCM rarely lives alone — these pair naturally with the revenue cycle.
Bring your denial report. Leave with a recovery plan.
One working session to find the RCM workflow with the worst rework-to-margin ratio — and the fastest path to an agent that fixes it.