Medical – Mid-Sized Multi-Specialty Practice (50+ Staff): Revenue-Cycle AI Fabric

Industry: multi-specialty outpatient. Size: 52 staff, 18 providers. Complexity: multi-payer, high prior-auth specialty mix. Systems: athena, clearinghouse, payer portals.

Manual re-keying, unclear ownership of auth status, and denials discovered late. Bottlenecks at auth submission and COB verification. Scale broke when new providers joined with different payer mixes.

Orchestrated pipeline: appointment → eligibility bot → auth workflow with document AI → claim generation checks → denial classification → appeal drafting with human sign-off.

1. Trigger: schedule create/modify.
2. AI eligibility: batch + real-time checks; patient SMS for gaps.
3. Structure: coverage object in DB.
4. Decision: auth required? which pathway?
5. Actions: fax/API submission; task nurses for clinical questions; scrub claims.
6. Humans: clinicians on clinical auth questions; finance on write-offs.
7. Loop: denial reasons refine rules and prompts.

Eligibility Agent, Prior Auth Agent, Claim Scrub Agent, Denial Triage Agent, Appeal Draft Agent.

HIPAA-aligned VPC, encrypted PHI, audit logs, athena APIs, RPA for legacy portals, PostgreSQL, LLM with de-identified prompts where possible.

athenahealth, Waystar, Twilio, PostgreSQL, OpenAI, RPA hooks, FHIR subset

Denials down 27%; prior auth turnaround improved 44%; FTE-equivalent 2.4 roles redeployed to patient-facing work; cash velocity improved 9% in 90 days.

Build: 12 weeks (compliance gates). Deploy: 4 weeks phased by site. Optimization: ongoing denial taxonomy.