Healthcare Admin — Document Operations

Healthcare admin AI without the offshore coding floor.

Document workflows for providers, payers, PBMs, and TPAs — prior auth, denial appeals, HCC coding, HEDIS abstraction, CPT/ICD-10 coding, charge capture, pharmacy PA, disability determination, WC medical review — into Epic, Cerner, athenahealth, Cohere, Surescripts, Inovalon, and your existing platform.

See the Workflows Take the AI Assessment ↓

The Landscape

The Templated Document Work Currently Outsourced to Healthcare BPOs

Most providers, payers, PBMs, and TPAs route templated healthcare-admin document work to large healthcare BPOs — Cognizant, Optum, Conifer Health, R1 RCM, GeBBS Healthcare Solutions, Access Healthcare, Sutherland, EXL Healthcare, AGS Health. Indian and Filipino medical coders cost $9–$18 per hour fully loaded; US-based coders run $25–$45 per hour. A 300-bed hospital typically spends $3M–$8M per year on coding alone. Prior authorization is a $35B labor problem nationwide; the average PA takes 12–18 minutes of nurse or admin time. Templated, rules-driven document work with a regulatory floor (HIPAA, 42 CFR Part 2, CMS-required PA timeliness, MA HCC submission deadlines, HEDIS measurement-year cycles, NCCI edits, state-specific WC guidelines) and a defensibility floor on payer denials, CMS audits, and state DOI examinations — that's the cell where AI workflows undercut the labor cost without changing the regulated entity's compliance posture. Last Rev replaces the BPO line item, not your EHR, your care-management platform, your HEDIS engine, or your PBM system.

Workflows

Pick the Workflow You Want to Replace

Each page below shows input, analysis, output, and the system of record we deliver into.

Workflow 01

Prior Authorization

Physician orders, clinical notes, lab and imaging results → InterQual / MCG medical-necessity match, payer-portal submission, status tracking. PA in 3 minutes, not 30.

Workflow 02

Clinical Denial Appeal Letter Drafting

Denial letters and medical records → payer-policy-cited appeal letters with evidence chronology. RN appeals writers and physician advisors freed up.

Workflow 03

HCC Coding Review (Risk Adjustment)

Progress notes, discharge summaries, problem lists → HCC capture per MEAT criteria. Direct submission to CMS RAPS/EDS at one-fifth the per-chart BPO rate.

Workflow 04

HEDIS / Stars Chart Abstraction

EMR access plus measure specs → A1c, BP, screening dates abstracted per HEDIS technical specs. Direct into Inovalon, Cotiviti, or Optum HEDIS engines.

Workflow 05

Inpatient & Outpatient CPT / ICD-10 Coding

H&P, op reports, discharge summaries → principal and secondary diagnoses, procedure codes, MS-DRG. AAPC / AHIMA-aligned coding into the 837 claim file.

Workflow 06

Charge Capture & Reconciliation

Charge tickets, EMR documentation, supply utilization, OR records → undocumented / late / missed charges identified. NCCI edits applied. Revenue capture report.

Workflow 07

Pharmacy Prior Authorization

Prescription, patient history, formulary, step-therapy → PBM PA submission with the fewest steps. Surescripts integration. $4–$12 per PA replaced.

Workflow 08

Disability Determination Services

SSDI / SSI medical evidence → SSA Listings or RFC assessment, decision rationale drafted for state DDS or federal contractor sign-off.

Workflow 09

Workers' Comp Medical Record Review

Injury reports, treating-provider notes, IME reports → causation analysis, treatment-plan compliance vs ODG / ACOEM, MMI determination, impairment rating.

Systems of Record

We Deliver Into the Platforms Healthcare Teams Already Use

Epic Cerner / Oracle Health athenahealth Cohere Surescripts Inovalon Cotiviti Optum HEDIS CMS RAPS / EDS InterQual / MCG ODG / ACOEM CMS-1500 / UB-04 / 837 AAPC / AHIMA standards HIPAA / 42 CFR Part 2 / HITRUST NCCI edits

Common Questions

What Providers, Payers, PBMs & TPAs Ask Before Engaging

Those are the systems of record where clinical, claims, prior-auth, and quality-measure data live. The competitor on this page is the BPO labor line on your operating budget — typically Cognizant, Optum, Conifer Health, R1 RCM, GeBBS Healthcare Solutions, Access Healthcare, Sutherland, EXL Healthcare, or AGS Health. We undercut that labor cost, integrate directly into your existing EHR / care-management / HEDIS / pharmacy / billing platform, and deliver structured artifacts (PA submissions, appeal letters, HCC codes, HEDIS measure data, CPT / ICD-10 coded encounters, charge corrections, pharmacy PA submissions, disability decision rationales, WC review reports) into the system of record.

Most providers, payers, PBMs, and TPAs keep the BPO arrangement in place during pilot and early production — we route exceptions, complex clinical scenarios, and any case that genuinely requires senior-clinician or senior-coder judgment to the team you already have. Volume to the BPO drops 60–85% on routine document workflow once cutover completes. You renegotiate at the next renewal from a much better position, or shift the relationship to higher-complexity work like complex appeals, multi-condition HCC validation, or specialized coding work.

Every extraction, finding, and routing decision is logged with the source document, model version, prompt, and confidence score. PHI is encrypted in transit and at rest. The audit log produces the basis for every clinical-evidence finding on demand — supporting CMS audits (RADV, OIG), payer denial defenses, and state DOI examinations. Final clinical and coding determinations remain with the regulated entity (provider, payer medical director, or coder).

Yes — through the documented integration surface each platform supports. Epic via App Orchard / FHIR APIs; Cerner / Oracle Health via FHIR APIs and Cerner Open Developer Experience; athenahealth via REST APIs; Cohere via published integration patterns; Surescripts via the prescriber-portal integration; Inovalon, Cotiviti, and Optum HEDIS via documented integration patterns; CMS RAPS / EDS via the standard submission feed. Your IT, clinical, and compliance teams review and approve service accounts. We do not require platform-side custom development.

A single workflow — prior auth, denial appeal, HCC coding, HEDIS abstraction, charge capture — typically runs a 6–8 week pilot on a constrained scope (one specialty, one payer, one product line, one site). Production cutover happens when the pilot meets your accuracy and SLA bar plus clinical / coding-management sign-off. Multi-workflow rollouts are phased; we do not try to replace your entire BPO stack in one go.

We benchmark against your current BPO unit cost — typically $9–$18 per hour for offshore coders or $25–$45 per hour for US-based coders translated into per-event economics ($1.50–$6.00 per HCC chart, $2–$8 per HEDIS chart, $4–$12 per pharmacy PA, $50–$200 per appeal). Our target is 25–45% of that per-event cost at higher accuracy and faster cycle time. Pricing structures around volume tiers and outcome SLAs, not hourly billable rates.

We don't make the clinical or coding determination. We tag the clinical record with the indicators and source evidence so your clinician, coder, or medical director makes the call on a richer file than the BPO produces today. The audit log produces the per-finding basis for any payer denial, RADV audit, OIG review, or state DOI examination on demand.

Two Ways to Start

Take the AI assessment if you want a structured read on where AI fits in your healthcare-admin document workflows. Talk to us if you already know which workflow is bleeding the most BPO labor cost.

Self-serve · 8 minutes

Take the AI Assessment

A short structured assessment that maps your healthcare-admin document workflows to AI feasibility and ROI. You get a tailored read in your inbox — no sales call required to see it.

Talk to a specialist

Talk to a Healthcare Admin AI Specialist

Tell us your top three workflows by labor cost, your EHR / care-management / HEDIS / PBM platform, and your current BPO arrangement. We'll come back with a per-event ROI model and a 6–8 week pilot plan in 5 business days.