Healthcare Billing & Denial Resolution Agent
A Singapore healthcare provider proposed an AI agent to streamline claim denial investigations, payer research, follow-ups, and specialist review.
Business Process Challenges
The healthcare provider’s billing teams had to investigate claim denials by reviewing claim records, payer requirements, supporting documents, and previous communications across separate systems. Denial reasons could be unclear, documentation could be incomplete or inconsistent, and important follow-up deadlines could be missed when investigations depended on manual searches and handoffs.
Key challenges included:
- Manual claim investigation: Billing specialists spent significant time reviewing rejected claims, claim history, and supporting records to understand the reason for each denial.
- Incomplete documentation: Missing or inconsistent billing documents made it difficult to determine whether a claim contained sufficient evidence for further action.
- Payer requirement discovery: Teams had to manually locate the applicable payer policies, billing requirements, and documentation guidelines for individual cases.
- Follow-up management: Repeated payer follow-ups and deadline tracking created additional administrative work and increased the risk of overdue actions.
- Complex case handling: Cases involving conflicting evidence, complex policy questions, or sensitive decisions required specialist review and appropriate audit trails.
Our Strategic Approach
Softree proposed an AI Healthcare Billing & Denial Resolution Agent using Amazon Bedrock, Amazon Bedrock AgentCore, and retrieval-augmented generation (RAG). The solution connects approved claims systems and document repositories with payer guidance to support structured investigations and route unresolved cases to billing specialists.
- Claim context gathering: The agent retrieves authorized claim history, denial codes, previous communications, and supporting documents to establish a complete case context.
- Payer requirement retrieval: RAG searches approved payer policies, billing guidance, and documentation requirements relevant to each claim.
- Denial classification: The agent proposes a denial category, identifies missing or inconsistent evidence, and provides a summarized rationale with source references.
- Follow-up preparation: The solution drafts document requests, payer follow-ups, and appeal preparation notes for billing specialists to review.
- Specialist routing: Cases involving conflicting evidence, complex policy questions, or approaching deadlines are routed to authorized billing staff.
- Controlled operations: Permissions, human review, monitoring, and audit logging govern sensitive claims data and downstream actions.
Our Engineering & Delivery Process
Our structured project delivery approach takes you from discovery and planning to development, testing, and deployment, ensuring quality, transparency, and predictable outcomes at every stage.
Discovery & Architecture
Deep-dive technical audit of existing systems, security baselines, API mapping, and comprehensive cloud target blueprinting.
UX & System Prototyping
Role-based user journeys, wireframing, high-fidelity clickable Figma prototypes, and API contract specifications prior to build.
Agile Sprint Engineering
Modular development sprints delivering clean, shippable code with automated CI/CD pipelines and continuous testing.
QA & Security Hardening
End-to-end regression suites, cross-device verification, load stress audits, and penetration testing for enterprise resilience.
Production Launch & Scale
Zero-downtime blue-green production deployment, real-time telemetry, administrator training runbooks, and ongoing SLA support.
Explore the Solution Through visuals
What changed for the client.
The proposed solution is designed to help billing teams spend less time searching through claim records and payer requirements and more time reviewing cases that require specialist attention. Structured summaries, source-linked payer guidance, and prepared follow-ups are intended to improve consistency and case visibility.
The proposed pilot targets improvements in:
- Reduced manual effort when gathering claim history and payer requirements.
- More consistent identification of missing or conflicting documentation.
- Clearer prioritization of follow-ups based on urgency, status, and next action.
- Faster preparation of denial summaries and draft communications.
- Improved case visibility across ownership, status, follow-ups, and escalation.
The numbers behind the rollout.
The full integration layer.
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