SOLUTIONS · HEALTHCARE REVENUE CYCLE
Healthcare operations
AI revenue cycle management is the use of AI agents to do the reading, checking and chasing work between a patient visit and the final payment: eligibility, prior authorization, coding review, claim scrubbing, denials and appeals, underpayment checks against contract, payment posting and A/R follow-up. OutcomeCatalyst builds and runs it for multi-site physician groups, ASCs, and specialty and behavioral health practices, on top of the EHR, practice management system and clearinghouse they already use. Your billing team approves every appeal, write-off and patient-facing message. The goal is one number you name up front, such as cost to collect or net days in A/R, moving in the right direction.
The problem, in the words we hear on calls
"We have six people working denials and nobody can tell me why they are going up." That is the CFO version. The practice administrator version is shorter: "Everything is in a different place."
A twenty-location group usually runs one EHR (two after an acquisition), a practice management system, a clearinghouse, several payer portals, a folder of contract PDFs and a spreadsheet someone built to track appeals. The trouble is that the answer to "why did one commercial payer pay the knee arthroscopies at Location 4 eleven percent under contract last quarter" needs four of them at once, and no single system holds all four pieces.
In Experian Health's 2025 State of Claims survey, 41% of providers reported denial rates of 10% or higher, missing or inaccurate data was the top denial cause at 50%, and 90% of denials were reworked with at least some human review (Experian Health, 2025). The AMA's 2024 physician survey found practices complete an average of 39 prior authorizations per physician per week (AMA, 2024). And medical groups are moving: in a September 2025 MGMA Stat poll, 68% of groups said they added or expanded AI tools in 2025, with revenue cycle work the most common planned target (MGMA, 2025).
So the real question is how to add AI without ripping out athenahealth, eClinicalWorks or whatever the group already runs, and without buying five point tools that do not talk to each other.
RPA, point tools and agents: what is actually different
Approach | What it does well | Where it breaks |
|---|---|---|
RPA bots | Repeat the same clicks on the same screen fast, such as checking claim status on a payer portal. | A portal redesign stops the bot. It follows steps; it cannot read a denial letter and decide. |
Clearinghouse and PM rule edits | Catch format errors, missing modifiers and known payer edits. Large vendors such as Waystar now add AI trained on very large claim volumes. | They see the claim, usually not your contract terms, the note, or which location repeats the same front-desk error. |
AI agents on a shared context layer | Read the denial, the note, the contract and the history, decide the next step the way your best biller would, and draft the work for approval. | Only as good as the data they reach and the rules your team wrote down. Without the connected layer, an agent is a smarter bot with the same blind spots. |
We think the third row is where the money is for a physician group, and its last cell is why most revenue cycle AI pilots stall. The model is rarely the problem. The connected record underneath is. More in denial and underpayment detection needs a data layer.
What OutcomeCatalyst does, step by step
OC is delivered and run by our team. You do not license a tool and staff a data project.
Name the unit. Before anything is built, we agree on the countable thing the agents will move and measure today's baseline. If we cannot name it, we do not start.
Connect the systems you already run. We read from the EHR, the practice management system, the clearinghouse remits, payer portals, the contract folder and the spreadsheets where they sit. Those connections feed a knowledge graph we call the brain, which links each encounter to its patient, location, provider, payer, contract rate, claim lines, remits and every appeal letter.
Write down how your veterans decide. We sit with your senior billers and coders and capture the rules they apply without thinking: which payer needs a modifier 25 note attached, when a timely filing denial is worth a fight, which underpayments are below the threshold to chase. Your team signs off.
Deploy agents on live work. Agents work real claims and queues, show the source for every fact, and stop where a person has to approve.
Measure and tune. We report the unit against baseline and fix rules your staff overrode.
Where agents work in the revenue cycle
For the order to tackle these in, read our revenue cycle management automation guide. Here is what each looks like when OC runs it.
Eligibility and benefits
The agent checks coverage before the visit, compares the payer response with registration, and flags a terminated plan, a new secondary or a missing referral. Front-desk staff get a short fix list per location.
Prior authorization
The agent reads the order and payer rules, decides whether an auth is needed, builds the packet from the chart and tracks it to a decision. For referral-driven specialties, the referral and access agent handles intake, eligibility and auth requirements the day a referral arrives.
Coding assist
The agent reads the note and suggests codes and modifiers, with the sentence in the note that supports each one. A certified coder accepts or changes the suggestion. The agent does not finalize codes.
Claim scrubbing
Your clearinghouse edits still run. The agent adds checks that need context the clearinghouse lacks: your denial history by payer and location, contract billing rules, and the documentation gaps behind last month's denials.
Denials and appeals
The claims and appeals agent reads each denial, groups it by root cause, payer and location, and drafts the appeal with the supporting note and contract language attached. A biller reviews and sends. Patterns feed back to the front desk so the same denial stops recurring.
Underpayments against contract
Most groups never get to this. A payer can close a claim as paid and still pay less than the rate it signed. The agent compares each remit line to the contract amount, flags the variance and drafts the dispute for approval.
Payment posting
The agent matches remits to claims, queues clean postings for review, and routes takebacks, partial payments and unmatched deposits to the right person with context attached.
A/R follow-up
Instead of working the aging report top to bottom, staff get a queue ranked by dollars, filing deadline and odds of payment, with status checked and the next action drafted.
The systems it reads
EHR and practice management: encounters, charges, notes, scheduling and registration.
Clearinghouse: claim submissions, rejections and 835 remittances.
Payer portals: eligibility, claim status and auth status.
Payer contracts and fee schedules, including the PDFs nobody has keyed.
Spreadsheets and inboxes where appeal tracking actually lives.
Nothing is replaced. Your EHR and PM system stay the record of truth, and we confirm the access route for your specific systems during scoping before anything is built.
What stays human
Agents read, match and draft. Calls with clinical, legal or relationship weight stay with your people by default:
Final code selection and any coding that affects risk adjustment.
Sending appeals, disputes and any letter to a payer.
Every message to a patient, including balance and estimate communication.
Write-offs, adjustments and decisions to stop chasing a balance.
Escalations to payer reps and contract renegotiation.
Some groups later let narrow, low-risk work, such as posting a remit that matches contract to the cent, pass with lighter review. That is your call, made on approval-log evidence. We start with it off.
What to measure: name the unit first
HFMA's MAP Keys define 29 standard revenue cycle measures across patient access, pre-billing, claims, account resolution and financial management (HFMA, MAP Keys, accessed 2026). Pick one as the headline. Projects that try to move eight metrics end up proving none.
Unit | What it tells a CFO | Best fit when |
|---|---|---|
Cost to collect | Revenue cycle spend per dollar collected | Headcount and outsourcing costs are the pressure |
Net days in A/R | How fast billed revenue turns into cash | Cash flow is tight or A/R over 90 days keeps growing |
Net collection rate | Share of collectible dollars you actually collect | You suspect leakage from underpayments and abandoned denials |
Initial denial rate by payer and location | Where the front end is breaking | Denials are rising and nobody can say why |
Underpayment dollars recovered | Money owed under contract that was never paid | Payer contracts are complex and nobody checks remits against them |
For most multi-site physician groups we would start with net collection rate, because it captures both denials that were dropped and underpayments that were never seen. A group under staffing pressure should pick cost to collect instead.
Notes for ASCs, specialty and behavioral health practices
ASCs depend on implant carve-outs, multiple procedure rules and case rates, so the contract check usually pays first. Specialty groups see the most denials around prior auth and modifiers. Behavioral health adds time-based codes, visit-count auth limits and, for substance use disorder records, 42 CFR Part 2 consent rules that limit what an agent can touch. We scope that access with your compliance lead before anything connects.
How a project starts
A first conversation is about one problem and one unit, not a platform tour. We ask for a recent denial and remit sample, your systems by location, and the two or three payers that cause the most pain. Then we tell you whether the data supports the unit, which agent goes first and what your team does during setup. If the data cannot support it, we say so. For the strategic case on building this yourselves, see buy vs build an AI context layer.
Frequently asked questions
Do we have to replace athenahealth, eClinicalWorks or our PM system?
No. OC reads from the systems you run and writes back only where you approve it. We confirm the access route for your specific systems, whether an API, a report export or a database read, during scoping.
How is this different from the AI our clearinghouse already sells?
Clearinghouse AI is good at claim-level edits. It typically does not see your contracts, clinical notes and location history together. OC connects those so an agent can find why a denial happened and whether a paid claim was paid correctly. Many groups keep both.
Do we need a data team to run this?
No. OC builds, runs and maintains the connections, the knowledge graph and the agents. Your billing leads approve agent work and tell us when a rule is wrong.
Will the AI send appeals or contact patients on its own?
Not by default. Agents draft appeals, disputes and patient messages into a queue, and a person on your team sends them.
What happens after go-live if our billers do not use it?
Then the project failed, and we count that as our miss. We watch approval rates and overrides, sit with the staff who skip the queue, and change the agent until it saves them time. Adoption stays inside the engagement after go-live.
What are your security and compliance standards?
OutcomeCatalyst is HIPAA-aligned and SOC 2 Type 2 aligned, with the formal audit underway and expected to complete before year-end. Agents see only what the person they work for can see, access to clinical systems is read-only unless you approve otherwise, and every agent action is logged.
Sources
Experian Health, "3rd Annual State of Claims Survey Finds Denials Still on the Rise," September 22, 2025: experianplc.com
American Medical Association, "Fixing prior auth: Nearly 40 prior authorizations a week is way too many," 2024 AMA prior authorization physician survey: ama-assn.org
MGMA Stat poll, September 30, 2025, AI adoption in medical groups: mgma.com
HFMA, MAP Keys revenue cycle KPIs: hfma.org
TechTarget RevCycle Management, "Waystar adds agentic AI in move to autonomous revenue cycle," January 2026: techtarget.com
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