The front-end fact
Front-end denials are 41% of all denials; registration and eligibility alone are 27%.Change Healthcare Denials Index Information gaps at scheduling compound at every step downstream.
Blueprints Healthcare & Life Sciences Providers · Revenue Cycle
Revenue Flow
The denial is caught upstream, or it costs everything downstream. Revenue Flow puts six agents on the upstream side. Routine submissions clear autonomously. Analysts drive the calls that need judgment, and curate the knowledge base every cycle.
Start a SprintRCM runs on the institutional knowledge of analysts who have learned which payer denies which procedure under which clinical pattern. Today that knowledge sits in their heads and walks out the door at every shift change.
Revenue Flow brings it to the surface.
Six agents review eligibility, prior auth, documentation, coding, and claim compliance. The routine 99% clears at Tier 1 confidence. Critical decisions, escalations, and Layer 3 pattern approvals stay with the analyst.
The context
Three facts.
One mandate already in effect.
The data fact
Half of revenue-cycle leaders now name missing or inaccurate data the #1 driver of denials, up from 46% the prior year.Experian Health, 2025 State of Claims Initial denial rates rose to 11.8% in 2024 from 10.2%.
The mandate, already live
CMS-0057-F operational rules took effect January 1, 2026. Payers respond to expedited PA in 72 hours and standard requests in 7 days. API requirements follow January 1, 2027.CMS Final Rule CMS-0057-F Payers automate. Providers who do not absorb the cost.
Front-End Denials
41%
Share of denials originating before adjudication. Registration and eligibility alone account for 27%.
Change Healthcare Denials Index
Denied Claims Never Reworked
65%
The majority of denied claims are written off rather than appealed. The loss is permanent, not deferred.
MGMA, cited in Becker's Hospital Review
Cost Per Appeal
$118 / claim
Average provider spend per appealed claim, against a $25 baseline rework cost. Roughly $8.6B in administrative cost nationwide.
Becker's Hospital Review · Change Healthcare data
The math
The leak is upstream. So is the fix.
What it costs to wait
Average rework per denied claim: $25.MGMA Provider spend per appealed claim: $118.Becker's 65% of denied claims are never reworked. For a $36M claims base, a 5-point denial-rate reduction recovers $1.2M before labor savings on appeals never run.
What prevention is worth
AI-enabled providers report 30–50% denial-rate reductions.McKinsey, AI in Healthcare Catching an eligibility gap at scheduling costs seconds. Catching it after adjudication costs $118, a 30-day delay, and a coin-flip on the appeal. Same information, different cost.
The compounding return
Every denial the system handles becomes a Layer 3 pattern candidate. Patterns the analyst approves feed back into Intake and Authorization. The prior-auth gap that caused last quarter's denial flags automatically this quarter. Joint targets we would expect to set with a partner: under 5% on prior auth, under 8% on coding, under 3% on policy violations.
The CFO view
A live scorecard the CFO opens once a day.
The agents do the work. This is the surface where the work shows up. Industry-benchmarked baselines, joint targets refined with a partner in Sprint, illustrative numbers drawn from public benchmarks. The design is the deliverable.
Revenue Flow · Live
CFO Scorecard · Trailing 30 days · Updated 14:32 ET
Initial Denial Rate
8.4%
↓ 3.4 pts vs. baseline
Baseline 11.8% · Experian 2024
Clean Claim Rate
94.1%
↑ 5.0 pts vs. baseline
Industry benchmark ≥ 95%
Days in A/R
36 days
↓ 9 days vs. baseline
MGMA target ≤ 40 days
Appeal Overturn Rate
62%
↑ 11 pts vs. baseline
63% of denials are recoverable · CHC
Denial-Rate Trend · 12 weeks
Latest 8.4%
Baseline 11.8% (Experian) · Joint target floor 5.0% (refined in Sprint)
Agent Activity · Last 24 hours
Intake 1,847
Authorization 1,562
Scribing 1,303
Coding 1,422
Claims 1,683
Denial 462
Tier 1 autonomous · 85% of claims clear without analyst review
Quality drivers · What changed the curve
+88%
PA gaps caught
+74%
Doc gaps flagged
214
L3 patterns active
619
Pre-submit holds
Quality is the lever. Revenue follows it.
Revenue Recovered · Trailing 90d
$1.2M
Modeled against a $36M annual claims base at a 5-point denial-rate reduction. Excludes labor cost avoided on appeals not attempted.
Numbers illustrative · drawn from public benchmarks. The first 90 days of a Provectus engagement establish the actual baseline before any target is committed. The dashboard is the surface. The agents do the work.
The Blueprint
Six agents, three knowledge layers, one flow. The routine 99% clears autonomously. Analysts drive what matters.
Each agent shares state with the next, so Denial findings strengthen Intake checks on the next patient. Systems of record do not change. Pick a workflow, then any agent, to see how it routes.
Select a workflow
Layer 01 · Accountable
People in the driver's seat
Accountable · decides · liable
RCM Analyst
Drives queue, escalations, submissions
Clinical Coder
Drives CPT/ICD, modifier decisions
RCM Manager
Drives policy, thresholds, approvals
Physician
Drives clinical documentation, auth sign-off
Layer 02 · Provectus Specialist Agents
Six agents extending analyst reach across every phase
Reviewed · routed · audited
Layer 03
Systems of record. Unchanged.
Revenue Flow adapts. No replatform.
EHR / Epic
Payer Portal
Clearinghouse
CMS / LCD
Practice Mgmt
FHIR Records
Denial History
Payer Contracts
Audit Trail
Agent
Intake
Verifies eligibility, classifies the visit type, routes to the correct payer plan, and flags authorization requirements before the patient arrives. Addresses the most common denial category at its source: 41% of denials originate at the front of the cycle, with registration and eligibility responsible for 27% (Change Healthcare Denials Index).
What it reads and writes
- Reads: FHIR patient record, insurance plan, scheduled service, COB history
- Writes: eligibility status, visit classification, payer routing, pre-service flags
- Source systems touched: EHR/Epic, payer portal, FHIR records
Where the analyst drives
Routine eligibility clears at Tier 1 confidence and never reaches the queue. The analyst reviews escalations: ambiguous COB sequencing, payer routing that conflicts with the patient's plan, and edge cases the KB has not yet seen. Layer 3 pattern candidates surfaced here require analyst approval before they become rules.
In this workflow
Prior auth prevention. Routine eligibility and standard PA packets clear autonomously. The analyst owns the escalations: peer-to-peer review, payer-policy conflicts, novel denial-risk patterns. Agents validate. Analyst decides on the cases that need judgment.
Active for selected workflowIdle / not invoked
Knowledge Base · The Keystone
Knowledge Base management is the moat.
Rule-pack vendors ship static logic. Provectus ships the refresh loop and a three-tier rule structure. Analysts curate the rules. The customer owns the resulting KB.
The structure
Three tiers, layered. Tier 1: NCDs and universal rules. Tier 2: LCDs, MAC, payer-specific. Tier 3: institution-tuned, learned from your denial history. The system recommends. Analysts curate.three tiers · per payer × specialty · refreshed weekly
The lever
Every denial and every approval updates the KB per payer × specialty. The loop runs on five steps: Submit, Observe, Diagnose, Update, Deploy. Analysts review what the system learned before it becomes a rule. The system compounds.
The asymmetry
Rule packs are copied inside a quarter. An institution-tuned refresh loop is not. The KB carries the privately negotiated rule one billing specialist learned over three years, and the appeal language that actually overturns. The customer owns it at the end.
1
Tier 1 · Universal
CMS NCDs, AMA CPT, NCCI edits. Updated as regulations change. Common across every customer.
2
Tier 2 · Regional / Payer-specific
LCDs, MAC jurisdiction rules, payer medical policies, plan-level thresholds across UHC, Anthem, Aetna, Medicare, Medicaid, BCBS.
3
Tier 3 · Institution-tuned
Patterns learned from your denial history. Carve-outs, internally negotiated rules, appeal language that overturned. The customer owns this tier at the end of the engagement.
three tiers · one knowledge base
fig. 12 · KB refresh loop
the loop compounds
What incumbents ship
A static rule pack.
Vendor-defined logic. Updated when the vendor updates it. Common across every customer who buys it. Copyable inside a quarter. The next vendor ships the same pack.
What Revenue Flow ships
A refresh loop and an institution-tuned KB.
Tier 3 is yours, learned from your denial history. The system recommends rules; your team approves. Weekly refresh per payer × specialty. The KB carries patterns no rule pack can ship. You own it at the end.
North Star · The Reimagination
Revenue cycle work, redrawn.
RCM today is a queue of tickets across six portals plus a drawer of Excel sheets, notes, and faxes. The reimagination is one chat that reaches every system and every loose file underneath.
One conversational control plane
Claude Cowork
direct the work · audit every agent decision
Structured systems
System
EHR / Epic
structured record
System
Payer Portal
lookups + submit
System
Clearinghouse
claims pipeline
Loose files
File
Excel sheets
billing trackers
File
Local notes
carve-outs · tribal
File
PDFs / Faxes
appeals · attachments
Human oversight
How agents and people work together. Four tiers. No black box.
Every agent action is assigned a confidence tier. The tier determines whether it proceeds autonomously, flags for review, holds for approval, or escalates to an SME. RCM managers set the thresholds.
Tier 1 · Confidence >95%
Automated
Agent proceeds and logs for audit. The 99% of routine work that clears at high confidence never reaches the queue.
Standard eligibility, in-network, routine claim, no PA
Tier 2 · 75–95%
Soft Escalation
Agent acts and flags for review. Analyst can approve, modify, or override. Pipeline does not block.
Minor doc inconsistency, auto-corrected, flagged
Tier 3 · <75%
Hard Escalation
Agent pauses for explicit approval. The case surfaces with full reasoning, citations, and recommended action.
Prior auth requiring peer-to-peer clinical review
Tier 4 · Novel / compliance
Expert Review
Escalates to a subject-matter expert: compliance, clinical, or legal. Full audit trail attached.
Multi-state workers' comp, novel payer interpretation
Key use cases
Four moments that define the revenue cycle.
Four places agents protect quality.
UC-01
Prior Auth Prevention
Authorization validated against payer policy, MAC jurisdiction rules, and ABN workflows before the procedure is scheduled. Standard packets clear at Tier 1 and submit autonomously. The analyst owns the escalations: peer-to-peer reviews, denial-risk outliers, novel payer states. Target: prior auth denials under 5%.
UC-02
Documentation, Coding & Claim Scrubbing
Scribing flags doc gaps in real time during the encounter. Coding validates CPT/ICD, NCCI bundling, modifiers, split billing. Claims gates the pre-submission check. Routine codes clear at Tier 1; the coder reviews escalations the medical-necessity check holds. Targets: coding denials under 8%, policy violations under 3%.
UC-03
Denial Management & Prevention Loop
Denial Agent performs root-cause analysis, drafts appeals with CMS citations, and extracts a Layer 3 pattern candidate. Standard appeals route autonomously. The analyst reviews the appeals that need judgment and approves every Layer 3 pattern before it becomes a rule. The learning loop is human-curated. Target: appeal overturn above 60%.
UC-04
Payer Intelligence
Three knowledge layers injected into every agent prompt at runtime. L1: 47+ base rules from CMS, LCD, AMA CPT, NCCI. L2: payer policies across UHC, Aetna, Cigna, Medicare, Medicaid, BCBS. L3: provider-specific patterns from your denial history. The RCM manager curates which Layer 3 candidates promote to active rules.
Side by side
Where the denial is caught changes everything.
The gap is discovered after adjudication. The cost is maximum.
Revenue cycle timeline · where problems surface today
Outcome
12+ manual touchpoints. Denial discovered 30–60 days after the visit. Rework or write-off.
The information to prevent this denial existed at scheduling. No one checked it in time.
The bet
The intelligence already exists. Revenue Flow brings it to the surface, then makes it compound.
The best RCM analyst on your team carries payer patterns that took years to learn. Revenue Flow extracts that knowledge, encodes it in three layers, and lets every agent act on it. Then it learns from what it gets wrong.
The reading
Payers automate adjudication. Appeals need to be specific. Revenue Flow's inline citations link every agent decision to source: CMS LCD L34869, AMA CPT 27447, payer medical policy. Auditable. Appealable.
The posture
Revenue Flow sits above your EHR, clearinghouse, and payer portals via FHIR and MCP. You do not replatform. Epic stays Epic. The agents extend what your analysts already do inside it.
The asymmetry
Every denial becomes a pattern candidate. Every analyst-approved pattern becomes a rule. The next run is smarter. The learning loop requires the agentic architecture to exist first, which is why programs that bolted AI on top of existing workflows cannot replicate it.
The window
CMS-0057-F operational requirements took effect January 1, 2026. API requirements follow January 1, 2027.CMS Final Rule Teams that build agentic prevention in the gap year carry an operational advantage when the API mandate hits.
The risk
What we do not know.
What we will not do.
What we don't
Your specific payer contract terms, your internally negotiated plan-level rules, your historical denial taxonomy, the Layer 3 patterns your team has accumulated over years. We find out together, on one service line, before we claim anything further. Sprint produces a confidence range, not a promise.
What we own
Revenue Flow sits above your EHR, practice management system, and clearinghouse, adapting to what you run today. Routine submissions clear autonomously with full audit trail; Tier 3 and Tier 4 escalations require analyst sign-off. HIPAA controls stay yours. The accountability line stays with your team.
The engagement model
Outcome-first. Parallel.
Skin in the game.
Three phases. One service line in Enable. Provectus operators join your RCM team and run old and new in parallel through one billing cycle. We scale only once the comparison favors Revenue Flow on every metric.
01 / Sprint
Weeks 1–2
Assess and pick one service line.
- Map payer mix, prior auth pain points, denial taxonomy, and EHR integration surface.
- Pick one service line for Enable, where authorization and denial pain shows most acutely.
- Define the shared scorecard: denial rate, clean claim rate, days in A/R, appeal overturn.
02 / Enable
One billing cycle
Run old and new in parallel. Same claims.
- Provectus operators sit on your RCM crew through Enable.
- Existing workflow and Revenue Flow run in parallel on the same service line, same billing cycle.
- Head-to-head on every metric. Joint accountability for the outcomes, not just the software.
03 / Realize
Cycle over cycle
Scale across service lines. Own the outcomes.
- Expand to remaining service lines once Enable proves out on the scorecard.
- Layer 3 pattern library compounds as each cycle adds to the denial history.
- Business outcomes tracked and reported: denial rate, days in A/R, clean claim rate, ROI.
Fig. 07 · Enable phase · one service line, two workflows, one billing cycle
Source · Sprint output
One service line · one billing cycle · same claims
Same payer mix and denial taxonomy split into two parallel runs.
Track 01 · Today
Existing workflow.
Customer RCM team. Same service line. Same billing cycle. Run as it runs today, no changes to existing process or systems.
Today's result
Scorecard A
Track 02 · Revenue Flow
Agentic workflow, joint team.
Provectus operators on the customer crew. Six agents with the three-tier KB. Same service line, same cycle, parallel run.
Revenue Flow result
Scorecard B
Compare · head-to-head
The comparison decides whether we scale.
- Denial Rate
- Days in A/R
- Clean Claim Rate
- Appeal Overturn
No progress without proof
Provectus operators sit on the crew. We run one service line with your team through one billing cycle. The same claims produce two scorecards. The head-to-head decides whether we scale, measured on denial rate, days in A/R, clean claim rate, and appeal overturn.
Commitments
What we sign up for.
Bounded confidence
One service line in Enable. One billing cycle of parallel runs. Head-to-head on denial rate, days in A/R, clean claim rate, and appeal overturn. We scale only when the comparison favors Revenue Flow.
Honest unknown
We do not know the ceiling of agent accuracy on your payer mix, the fit of your Layer 3 pattern library, or the voice of your appeal letters until we run them against yours. Sprint returns a confidence range. Enable turns it into evidence, or it doesn't.
Named trade-off
Revenue Flow sits above your EHR and clearinghouse, not inside them. We accept that constraint. It keeps the HIPAA audit story clean and the adoption path short. It also means we will not chase problems that belong inside your practice management platform.
Next Step
Let's start with one specialty, one payer.
If Revenue Flow looks like the right shape for your team, the next step is a Baseline Assessment. One to two weeks. Read-only. No workflow change for the clinician. We measure denials by specialty × payer, identify the beachhead slice, and decide together whether to proceed. If the assessment does not support a strong business case, we say so openly and recommend the right next step.
Schedule a working session
Stepan Pushkarev CEO, Provectus