Revenue-integrity teams
Continuous three-way reconciliation replacing periodic sample audits.
Revenue Cycle · AI Agent
Charge Reconciliation / Revenue Integrity AI
The agent reconciles what was documented against what was charged and billed, catching missing charges, CDM mismatches, and coding inconsistencies before the claim goes out — routing every proposed fix to a coder for approval.
Human-in-the-loopHIPAA-ReadyAudit LoggedCDM-aware
Trusted by global innovators
Revenue leaks between the chart and the claim
Every documented service should map to a charge, and every charge to a correct CDM entry — but services go uncharged, charges post against stale or mismatched Charge Description Master codes, and documentation contradicts what was billed. This charge leakage drains revenue and creates compliance risk, hard to catch by manual audit. The agent reconciles continuously: it compares clinical activity against posted charges and the outbound claim, validates each charge against the current CDM, and flags missing charges, unit mismatches, and code inconsistencies. Each finding routes to a coder or revenue-integrity analyst — the agent proposes corrections, it never edits a charge on its own.
Reconcile chart, charge, and claim
Reference architecture for how this agent connects to your EHR and data systems.
Key Capabilities
Charge capture and reconciliation grounded in the CDM and the actual clinical-to-claim data flow.
Missing-charge detection
Compares documented services and orders against posted charges to surface work performed but never charged — the core of charge-capture leakage.
CDM validation
Checks each charge against the current Charge Description Master for retired, mismatched, or mispriced codes.
Three-way reconciliation
Reconciles clinical activity, posted charges, and the outbound X12 837 claim, flagging quantity, unit, and code mismatches before submission.
Documentation-to-charge consistency
Cross-checks the clinical note and coded charges for contradictions — a billed procedure with no documentation, or a documented service with no charge.
Who runs it
Deployment scenarios
The same agent, aimed at where charges leak in your organization.
Hospital charge capture
High-volume departments — OR, ED, infusion, imaging — where missed charges add up fastest.
Physician & specialty groups
Documentation-to-charge consistency checks tuned to the group's procedures.
CDM management
Ongoing validation that charges post against current, correctly priced CDM entries.
Expected impact once the agent is live
Directional impact, validated per deployment rather than guaranteed.
Pre-bill
Missing charges and mismatches caught before submission
Continuous
Reconciliation instead of periodic manual audit
1 gate
Coder approval on every proposed correction
Compliance-First Healthcare App Development Services Backed by Global Standards
15-Minute Scoping Call01
HIPAA
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, strict access controls, and traceable audit logs.
02
GDPR
General Data Protection Regulation
Implement lawful consent flows, data minimization, retention controls, and secure processing for sensitive health data.
03
FHIR
Fast Healthcare Interoperability Resources
Enable standardized health data exchange across apps, care teams, and systems through robust FHIR-ready APIs.
04
HL7
Health Level Seven International
Support enterprise-grade interoperability with HL7-based integrations for records, events, and clinical messaging workflows.
05
HITRUST
Health Information Trust Alliance
Align security programs to healthcare-specific control and risk management practices trusted by providers and ecosystem partners.
06
HITECH
Health Information Technology for Economic and Clinical Health Act
Design with breach notification readiness, digital record safeguards, and operational controls that support regulated care programs.
07
SaMD
FDA Software as a Medical Device
Plan software quality, traceability, and documentation pathways for products that may require SaMD review and submission.
08
MDR (EU)
Medical Device Regulation (European Union)
Prepare EU market-ready processes for risk classification, evidence tracking, and lifecycle governance under MDR expectations.
09
SAMHSA
Substance Abuse and Mental Health Services Administration
Apply confidentiality controls and consent-aware sharing models for behavioral and mental health data experiences.
Standards it speaks
Data and controls
CDMX12 837CPT/HCPCSFHIR R4HIPAASOC 2
How It Works
Capture → reconcile → propose → write back
A four-stage pipeline that closes the gap between documentation, charges, and the claim.
1.
Capture the three sources
The agent ingests clinical activity from the EHR over FHIR, posted charges, and the outbound 837 claim, plus the current CDM, into one reconciliation view.
FHIR + charge intake
2.
Reconcile & detect
It matches documentation to charges to claim, validates against the CDM, and detects missing charges and mismatches — flagging low-confidence findings.
CDM-aware model
3.
Propose & human review
Each finding is explained and routed to a coder or revenue-integrity analyst, who approves, edits, or dismisses it. No charge changes without a human action.
Sign-off required
4.
Write back & track
Approved corrections and their rationale are written back to the charge and billing systems, and leakage trends captured for prevention analytics.
System write-back
Related proof of compliant AI delivery
Read Case StudyLera Health: compliant women's health platform
Related delivery proof from our compliant, AI-assisted healthcare work — not this exact agent.
Compliance & Guardrails
15-Minute Scoping CallGuardrails on every correction
In healthcare, the guardrails matter as much as the capability.
PHI handling
Clinical, charge, and claim data stay in HIPAA-ready, encrypted infrastructure under a BAA, with least-privilege access for the revenue-integrity team.
Human-in-the-loop
Every proposed charge addition or correction is reviewed by a coder or analyst; the agent detects and proposes, never edits a charge on its own.
Explainability
Each finding cites the documentation, charge, CDM entry, or claim line it compared, so reviewers can verify the discrepancy and defend it in audit.
Audit logging
Every reconciliation, finding, review decision, and write-back is timestamped and attributed.
Frequently Asked Questions
Yes. Clinical, charge, and claim data stay in HIPAA-ready, encrypted infrastructure under a signed BAA, with least-privilege access for the revenue-integrity team and full audit logging of every finding and correction.
Ready to close your charge-capture gaps?
Tell us your workflow and systems, and we'll return an architecture review and a phased rollout plan.
contact@agnotic.com
Partnerships
contact@agnotic.com