AI claim denial prevention trained on your own 835 remits. Every claim gets a payer-specific denial risk score, a named fix and an auth check before it is sent. Appeals that still happen get a drafted letter with the evidence attached.
AI claim denial prevention is software that scores each claim for denial risk before submission, using your historical remits, payer rules and the patient's eligibility and authorization status. It outputs a risk score, the likely denial reason (CARC), a suggested fix for the biller, and a prior-auth gap list. For claims that are still denied, it drafts an appeal letter citing the payer policy and chart evidence.
Denials are tracked as a back-end metric, but the causes sit at the front: registration, eligibility, authorization and missing data. By the time a remit shows the CARC code, the rework, the delay and the write-off risk are already locked in.
Average initial denial rate across more than 1,400 US hospitals in 2023, up from 9% in 2016.[1]
Of denials were potentially avoidable in the same analysis of 124 million hospital claim remits.[1]
Administrative cost per claim adjudicated reported by 280 US hospitals for 2023, up from $43.84 in 2022.[2]
A week spent on prior authorization by physicians and their staff, per the AMA's national physician survey.[3]
A model trained on two to three years of your own remits scores every claim by payer, plan and procedure, then explains the score in billing language.
Scans scheduled procedures, imaging and infusions days ahead and flags which ones need an authorization, which are expiring and which visit counts are near plan limits.
For claims that are still denied, drafts a first-level appeal citing the payer's own policy language and the relevant chart notes, ready for a biller to edit and send.
We load 24–36 months of 835s and 837s into your cloud account under a BAA, map CARC codes to root causes and agree the baseline avoidable-denial rate.
We train the risk model and replay the last 90 days of claims. You see which denials it would have caught, and which it would have held unnecessarily.
Live claims are scored before submission and shown to billers in your PM system or a side panel. Staff decide; we log every accept and override.
We compare denial rate, days in A/R and touches per claim on scored claims against baseline, and hand you a written go/no-go with the numbers.
| Criterion | Manual work queues | Clearinghouse claim scrubber | Stratgik build + run |
|---|---|---|---|
| What it catches | What a biller notices or a remit reports | Format errors and published payer edits | Format errors plus patterns learned from your own denials |
| When it acts | After the denial arrives | At submission | At scheduling (auth) and before submission |
| Prior authorization | Tracked in spreadsheets or notes | Usually not covered | Schedule-based gap check with chart packet |
| Appeals | Written from scratch | Templates | Drafted per claim with policy and chart evidence |
| Setup effort | None | Low; good for straightforward payer mixes | 21-day pilot with your remit history |
| Data location | Your systems | Vendor cloud | Your cloud account, BAA-covered model providers |
A denial that is later paid is not free. It costs staff time, delays cash and risks a timely-filing write-off. The cheapest denial is the one that never happens.
Adjust to your volumes. The share of denials prevented is an assumption; the pilot measures the real figure on your claims and payer mix.
Illustrative estimate using your inputs and stated assumptions, not a quote or guarantee. The pilot measures the real figure against your baseline.
21 days · one entity or specialty · your remit history
per month · production scoring and support
per month · multi-entity or hospital outpatient
Pilot and Run fees are fixed. Usage (model tokens, clearinghouse API calls, cloud) billed at cost with no markup and reported monthly; taxes excluded. GBP and AED prices are indicative conversions from USD.
Accuracy depends on your payer mix and how much remit history you have, so we measure it rather than promise it. In the pilot we back-test on your last 90 days of claims and report, by payer, how many denials the model would have caught and how many clean claims it would have held unnecessarily. You decide the hold threshold based on those two numbers.
A clearinghouse scrubber checks claims against format rules and published payer edits. Denial prediction learns from your own remits, so it catches patterns those rules miss, such as a payer that routinely denies a code pair at one location. It also runs earlier, checking authorizations against the schedule before the patient is seen. Most groups keep their scrubber and add this on top.
Stratgik's pilot is a fixed $18,000 over 21 days for one entity or specialty, measured on avoidable denials. Production runs at $4,500 a month, and multi-entity or hospital outpatient scale starts from $12,000 a month. Model and cloud usage is billed at cost. Use the calculator above to compare that with the rework and write-offs on your own volumes.
No software is compliant on its own; compliance depends on how it is deployed and operated. We design for HIPAA workloads: the system runs in your cloud account, PHI is encrypted in transit and at rest, access is role-based and logged, and we sign a BAA and use only BAA-covered model providers. Your compliance team reviews the setup before live claims flow.
Yes, mainly by finding authorization gaps early and assembling the paperwork. The agent checks scheduled services against payer requirements, flags missing or expiring authorizations days before the visit and builds the clinical packet from the chart. Staff still submit and track the request, and clinical judgment on medical necessity stays with your providers.
The production pilot takes 21 days: about four days to load and map remit history, a week to train and back-test, a week of shadow-mode scoring in your work queue, and a final measurement. Full rollout across additional entities typically follows in four to eight weeks, depending on how many practice management systems and clearinghouses are involved.
Book a 30-minute call. We will scope a 21-day pilot on one entity and agree the metric before any work starts.