Solution
For revenue cycle leaders, billing directors, and coding teams at provider groups and diagnostic labs: denial risk scored before submission, with every metric traced to the document behind it.
The problem
A coding mismatch that takes two minutes to fix pre-submission surfaces weeks later as a denial — and becomes a recovery project.
Authorizations wait while staff hunt medical-necessity documentation across the clinical record. Revenue waits with them.
Winning an appeal takes a clinical argument mapped to payer policy. Under volume, teams write off claims they could have won.
The product, not a promise
How it works
Ingest patient encounters, claim forms, and medical records in any format.
Rate every claim's denial risk against payer and coding rules.
Route high-risk claims to specialists with the specific mismatch identified.
Assemble prior-auth packets and draft evidence-backed appeal letters.
Track DSO, denial trends, and leakage on traceable dashboards.
Who it's for
Coding specialist
RCM director
Compliance officer
Revenue cycle teams lose money in predictable places: prior authorizations that stall for missing medical-necessity documentation, claims denied because a code didn’t match the clinical record, appeals that need expert clinical arguments nobody has time to write. For high-complexity diagnostics — molecular and genomic testing especially — generic billing tools can’t bridge the gap between the science in the record and the payer’s policy language.
The RCM Performance Suite reads the documents on both sides of that gap. It consolidates patient encounters, claim forms, and medical records in any format, and applies your payer and policy logic through a rule engine. Every claim is scored for denial risk before submission; high-risk claims route to a coding specialist with the specific mismatch identified, so the error is fixed before it leaves the building. Prior-authorization packets are assembled from the clinical record and submitted with the evidence payers require. When denials do happen, the suite drafts appeal letters that reference the patient’s history and the payer’s own policy guidelines.
Patients get clarity too: out-of-pocket estimates calculated from real-time eligibility and deductible status, before the service — which reduces surprise bills, abandonment, and bad debt.
Every anomaly the suite flags and every metric on the performance dashboards — turnaround times, denial trends, revenue leakage — is traced back to its origin in the claim or the clinical documentation. As your team reviews and corrects, the system learns and refines its predictions. Each denial-risk call is a recommendation that named staff approve, and the audit trail records who decided what and on which evidence. The result is fewer denials, faster reimbursement cycles, and numbers finance can defend to auditors and leadership alike.
Objections, answered
Every score names the rule it tripped and the exact mismatch between the billed code and the clinical record. The claim routes to a specialist as a recommendation; a person makes the call, and corrections feed back into the scoring.
That is the design. The rule engine runs your payer logic and policy thresholds, so claims are scored against the contracts you actually hold. New payer rules become configuration, without a rebuild.
Inside your deployment — Botminds cloud, private cloud, or on-prem — on a platform certified to ISO 27001 and SOC 2. Every flag, correction, and approval is logged for audit.
The suite ships as a working template. Point it at your claim formats, payer contracts, and policy rules; first production workflows are measured in weeks.
Watch the suite score the claim, name the specific mismatch, and draft the appeal — live, against your own payer rules.
Request a demo