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Congrats on the launch! I have a few questions (though I know very little about this space):

1. How often is the cause of a denied insurance claim a documentation error vs an intentional denial from an insurance company (either an automated system or medical reviewer)?

2. This feels very conceptually similar to an AI review bot, but the threshold for false positives feels higher. What does the process look like for double checking a false positive in the agent orchestration layer?

1 comments

Thank you!

1. It really depends on the clinical specialty, but the average is around 25% (e.g. 250M claims denied a year because of documentation mistakes). We work with rehabs where this ratio is above 50%

2. It's triple checking -tun the analysis twice and then verify the conclusion, 3+ separate agent calls

> We work with rehabs where this ratio is above 50%

Medical offices where more than 50% of the denied claims are because of documentation mistakes? I'm confused why they are still operating. Is this not malpractice of some kind?

For them it's a cost of doing business. Many of those claims will be paid after resubmissions (upon fixes the mistakes if it is possible) but the office operates with higher amount of working capital in this case

> For them it's a cost of doing business

"a cost of doing business" reads like they do not care that over half their denials are not real. You are working with business that do not care about humans and will use your tool to more extract profit. I'd rather them go out of business if they cannot get 50% of their claims done in a way that doesn't get them auto rejected.

Be careful what you wish for. We already have a shortage of healthcare providers. Do you want to make it harder to get an appointment? There's nothing wrong with billing at the maximum level legally and contractually allowed.

> There's nothing wrong with billing at the maximum level legally and contractually allowed.

I completely disagree with that statement. By nothing wrong, do you mean it isn't illegal?

It is horrible that some health care providers are denying more than half their claims incorrectly. A strawman argument about making it harder to get an appointment does not change that.

You seem to be mixing up providers and payers (insurers). Providers don't deny claims, but sometimes payers sent claims because the providers coded them incorrectly. There's nothing wrong with coding a claim with all services rendered and charging the maximum agreed rate. If the payers want a lower rate then they can negotiate it next time the contract is up for renewal.

Obviously it would be wrong for providers to bill for things they didn't actually do. That would be fraud. This part isn't in dispute.

Medical malpractice only applies to patient care, not administration. In other words, a provider can't be found liable for malpractice just because there's an error in the patient chart: there has to be some evidence of patient harm as well. Claim denials aren't a legal issue unless there is some sort of fraud or contact violation involved.

Now I understand your question. I can provide and example where a small documentation error may cause patient harm - wrong copy-pasting in a discharge note, copying from other personal medical record and accidentally pulling their diagnosis into the record, and then factoring this diagnosis by the other doctor in their treatment plan

I don't know then, gross negligence? ianal, but why is this an acceptable and profitable way to operate is beyond me.

Errors on a medical chart by themselves wouldn't legally constitute gross negligence (or even regular negligence). But if there was some sort of preventable patient harm then such errors could be evidence for establishing malpractice liability and/or professional sanctions.

In general patients should always check their own chart notes for errors. Most providers now make those available online for free through a secure patient portal.