🩺 AI autopilot · rcm

Medical-coding autopilot

Turns clinical notes into clean, compliant claims — a certified coder signs only the risky ones.

CFO / revenue-cycle leadbuys it $50–80Bmarket 5 auto · 1 humanflow steps
Building this market:

The problem

Manual medical coding is slow, expensive, and error-prone; miscoding drives denials and False-Claims-Act exposure.

What you get

Clean claims submitted straight-through; risky claims escalated to a certified coder; denials and overpayments handled.

The flow

Intake to outcome. 🤖 steps run automatically; 🧑‍⚖️ steps are where a named human signs off the judgment calls.

  1. 1
    🤖 Pull the clinical note from the EHR
    agent intake · EHR (FHIR)Document OCR
  2. 2
    🤖 Assign ICD-10 / CPT codes with the supporting note span
    agent coder · ICD-10 / CPT / HCPCS
  3. 3
    🤖 Run NCCI / MUE edits, medical-necessity, and the upcoding guardrail
    agent compliance · NCCI / MUE editsPayer rules / LCD-NCD
  4. 4
    🧑‍⚖️ A certified coder signs off below the confidence floor or on any FCA-high pattern Human checkpoint
    CPC / CCS certified coder
  5. 5
    🤖 Build and submit the 837 claim
    agent submit · Claims clearinghouse
  6. 6
    🤖 Track denials and refund overpayments (60-day rule)
    agent monitor · Claims clearinghouse

Agents & tools

  • EHR (FHIR) stub today → Epic
  • Document OCR stub today → AWS Textract
  • ICD-10 / CPT / HCPCS stub today → NLM Clinical Tables
  • NCCI / MUE edits stub today → CMS quarterly tables
  • Payer rules / LCD-NCD stub today → CMS coverage DB
  • Claims clearinghouse stub today → Change Healthcare

Connectors run as sandbox stubs today — flip to the real provider to go live.

Human checkpoints

  • CPC / CCS certified coder — A certified coder signs off below the confidence floor or on any FCA-high pattern

The autopilot escalates the judgment calls to a qualified human — the rest is straight-through.

Why it's safe to let it run

Every autonomous decision is logged — who · what · confidence. Signed human checkpoints and a built-in compliance reviewer enforce the rails, so the outcome holds up to an audit, not just a demo.

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