Revenue cycle management
A team of seven agents that takes a visit from booking through eligibility, prior authorization, coding and claims to denial appeals, with staff signing off at the risky steps.
Revenue cycle management is everything between a patient booking and the hospital being paid, and denials make it expensive.
About 15% of claims are denied first time
Private payers initially deny about 15% of claims, and over half of those are eventually paid.
Premier 2024 survey, via TechTargetFighting denials costs billions
Providers spend about $19.7 billion a year fighting denials. That is an industry-wide figure, not an estimate for one hospital.
Premier 2024 survey, via TechTargetPrior authorization now runs on a clock
Since 1 January 2026, Medicare Advantage, Medicaid and CHIP plans must decide prior authorizations within 72 hours (urgent) or 7 days (standard) and give a specific reason for every denial, which makes fast, complete files more valuable.
CMS-0057-F, summarised by Health SamuraiWhat the agent does
- 01
Books the visit and checks coverage
A patient access agent books the appointment by chat and takes a photo of the insurance card. An eligibility agent then runs the eligibility check and explains what is covered, the copay, the deductible left, and whether the visit needs prior authorization, with a cost estimate.
- 02
Assembles the prior authorization
A prior auth agent builds the packet: diagnosis, planned procedure code, clinical notes, how the case meets the payer’s medical policy criteria, and a list of missing documents. A scheduled workflow checks the decision every 4 hours.
- 03
Documents and codes the visit
A coding agent turns the visit transcript into a structured note and proposes ICD-10-CM, CPT and HCPCS codes with modifiers, each linked to the sentence that supports it. The eligibility agent then checks the coded services against the benefits and the approved authorization.
- 04
Builds, scrubs and submits the claim
A claims agent builds the professional or institutional claim, scrubs it for missing fields, code pairs, modifiers, the authorization number and timely filing, submits it, and reads the payer’s acknowledgment.
- 05
Works denials every night
A denials agent pulls remittances and claim statuses, reads the denial reason codes, decides between fix-and-resubmit and appeal, and drafts the appeal letter citing the payer’s own policy.
Checked before anyone sees an answer
The guardrail
Each agent has its own rule. The prior auth agent refuses to produce a packet if a criterion has no evidence; every proposed code must cite a sentence of the transcript; a claim with open scrub issues is blocked; coverage is always shown as an estimate, never a promise; and the booking chat gives no medical advice and tells emergencies to call 911.
Where a person steps in
A nurse or utilization reviewer approves every prior authorization before it is submitted, a certified coder approves the codes, a billing lead decides when a service is not covered, and an appeals specialist approves every appeal. The front desk calls the patient if coverage comes back inactive. In the first release nothing sends a claim or an appeal without a human approval step.
What is recorded
Every run has a trace of each agent step, tool call and source, with its cost. The team is emailed if a workflow run fails, and alerted if a case passes its deadline.
The steps, in order
Studio does the reasoning, routing, document assembly and review; connections to payers and health record systems come through custom tools that call a clearinghouse API. Three things need confirming before it handles patient data: a HIPAA business associate agreement covering Studio and every model provider it routes to, a speech-to-text step for the doctor’s dictation, and a licence for CPT codes.
| Step | What you do in Studio | Typical time |
|---|---|---|
| 1Build it with mock tools | Create the seven agents, the four workflows and all eleven tools, with each tool returning realistic synthetic data. Everything in Studio is real; only the outside systems are faked. | No outside systems needed |
| 2Real rails, test data | Replace the mocks with a clearinghouse in test mode and a real case store. Load ICD-10-CM, HCPCS, NCCI and one payer’s medical policies as knowledge. Write the test suites from de-identified past cases. | Days, not months, for the clearinghouse connection |
| 3Hospital systems | Connect the health record system, the scheduler and a scribe service; sign business associate agreements; limit agents that handle patient data to covered models; license CPT. | Depends on your systems |
| 4Pilot | One clinic, one or two payers, one service line such as outpatient imaging. Every human-review step stays on. Remove a review only where a step has a clean track record. | Until each step has a clean track record |
See it working
on your own information.
Tell us about your business and we will walk through this use case with you in Studio.