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Denial management and A/R platform for a billing company

One queue for denials and A/R across dozens of practices, ordered by money at risk and filing deadlines.

Illustrative scenario. Fictional multi-client medical billing organization. A fictional composite of the kind of work we do — not a real client engagement. Results marked [METRIC TO CONFIRM] are placeholders.

Client problem

Billers worked denials from three clearinghouse portals and a shared spreadsheet. The same denial reasons recurred every month and timely-filing deadlines were tracked from memory.

Existing environment

  • Two clearinghouses (SFTP + portal)
  • Practice-specific PMS exports
  • Shared spreadsheets per client
  • No central reporting

Challenge

Normalize 835 remittances from multiple sources, keep per-client payer rules separate, and prioritize work without hiding anything from staff.

Solution

An RCM workspace that ingests ERAs, categorizes denials by CARC/RARC, creates tasks with the suggested fix and deadline attached, and feeds recurring causes back into pre-submission scrubber rules.

Architecture

  1. 01835/277 ingestion workers
  2. 02Multi-tenant PostgreSQL (per-client isolation)
  3. 03Rules engine for prioritization
  4. 04LLM-assisted denial triage service
  5. 05Next.js staff workspace

Technology

  • Next.js
  • TypeScript
  • Node.js
  • Python
  • PostgreSQL
  • Redis queues
  • X12 835/837/276/277
  • AWS

AI integration

An assistant reads the remark codes, claim lines and payer history, groups denials by likely cause and proposes a next step. Low-confidence suggestions go to a human queue; staff approve every correction.

Workflow

  1. ERA received
  2. Lines posted automatically
  3. Denied lines categorized
  4. Task created with fix + deadline
  5. Biller reviews and corrects
  6. Replacement claim submitted
  7. Root cause added to scrubber

Result

  • [METRIC TO CONFIRM] reduction in days to rework a denial
  • Timely-filing deadlines visible on every open item
  • Recurring denial causes turned into pre-submission rules

Technical highlights

  • Idempotent 835 parsing with fixture library
  • Per-client payer rule sets
  • Full audit trail of every AI suggestion and human decision

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