Autonomous AI Billing for Workers' Compensation Practices

Scheduling Agent

Analyzes appointment patterns, flags high-risk no-show appointments, captures scheduling context (procedure type, referral source, insurance class) that affects downstream coding and billing decisions

For Workers' Compensation: validates CPT 99202-99215 and prevents causation not established.

Eligibility Agent

Queries 900+ payer databases in real time, validates active coverage, extracts benefit-level details (co-pay, deductible, out-of-pocket), identifies coverage gaps and prior auth requirements before the encounter begins

For Workers' Compensation: validates CPT 99202-99215 and prevents causation not established.

Documentation Agent

Converts encounter audio into structured clinical text using specialty-aware transcription models. Links every transcribed segment to the specific audio timestamp it came from, creating an immutable evidence chain. Formats output for the NOTE agent to structure into reviewable clinical documentation

For Workers' Compensation: validates CPT 99202-99215 and prevents causation not established.

Coding Agent

Reads structured clinical documentation, applies specialty-specific ICD-10 hierarchies and CPT code families, validates against payer-specific LCD policies and NCCI edit tables, applies correct modifiers, and proposes a complete reviewable code set linked to the clinical evidence that supports each code

For Workers' Compensation: validates CPT 99202-99215 and prevents causation not established.

Scrubber Agent

Scores every claim against 200+ denial variables before submission. Identifies modifier conflicts, missing prior authorizations, LCD coverage gaps, eligibility issues, and payer-specific policy violations. Routes high-risk claims for human review before they reach the payer, preventing denials at the source

For Workers' Compensation: validates CPT 99202-99215 and prevents causation not established.

Prior Auth Agent

Identifies prior authorization requirements from eligibility data and payer rules, assembles supporting clinical documentation, submits PA requests via payer APIs or electronic portals, tracks approval status in real time, and routes approvals back to the clinical workflow and Billing agent

For Workers' Compensation: validates CPT 99202-99215 and prevents causation not established.

Billing Agent

Submits validated claims to payer clearing houses or direct payer APIs, monitors submission acknowledgement in real time, tracks claim status through the payer adjudication process, flags abnormal hold times for follow-up, and passes accepted claims to the FLW agent for ongoing tracking

For Workers' Compensation: validates CPT 99202-99215 and prevents causation not established.

Denial Agent

Receives denial notifications, categorizes each denial by type (clinical necessity, coding, eligibility, authorization), retrieves original claim and clinical documentation, identifies the specific correction needed, assembles an appeal package with targeted documentation, and submits the appeal via payer portal or mail within the payer's filing window

For Workers' Compensation: validates CPT 99202-99215 and prevents causation not established.

Reconciliation Agent

Receives 835 EDI ERA files and EOB documents from payers, matches each payment line to the original claim, posts payments to the appropriate account, flags underpayments against contracted rates, identifies incorrect adjustment codes, calculates patient balance responsibilities, and generates reconciliation reports for financial review

For Workers' Compensation: validates CPT 99202-99215 and prevents causation not established.

Medsynthea + EPIC

SMART on FHIR bidirectional write-back for Workers' Compensation workflows.

Medsynthea + ADVANCEDMD

SMART on FHIR bidirectional write-back for Workers' Compensation workflows.

Medsynthea + ATHENAHEALTH

SMART on FHIR bidirectional write-back for Workers' Compensation workflows.