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.

RCM 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 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.

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

Metric Value Change Note
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

Denial-Rate Trend · 12 weeks

Latest 8.4% Baseline 11.8% 5.0% target 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

  • Prior Auth Prevention
  • Denial Management
  • Claim Scrubbing & Coding
  • Full Pipeline

Layer 01 · Accountable

People in the driver's seat

  • 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

  1. Intake: Eligibility, COB, payer routing
  2. Authorization: Prior auth, payer rules, denial risk
  3. Scribing: Real-time clinical documentation
  4. Coding: CPT/ICD, NCCI bundling, split billing
  5. Claims: Pre-submission compliance gate
  6. Denial: Root cause, appeal, pattern extraction

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, and 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 workflow

Idle / 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. Updated as regulations change. Common across every customer.
  • 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.

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 the 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 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.

02 / Enable

  • One billing cycle: Run old and new in parallel. Same claims.

03 / Realize

  • Cycle over cycle: Scale across service lines. Own the outcomes.

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.