The signature mechanic
Opt-in, balanced by construction, logged forever.
The module does nothing until a practice owner enables it with recorded disclosure. Once on, the suggestion stream is balanced — at least one downcode surfaces for every three upcodes — and every suggestion, acceptance, and rejection lands in a separate, immutable audit log. The hard guardrails are enforced in the engine, not in a settings screen.
This module consumes rules authored and versioned in Coding & CDS — it never authors them — and it can be disabled at any time. The competitive moat is the longitudinal record and the clinical workflow; payer navigation is a bounded feature, never the moat.
The problem
Under-coding out of fear. Denials out of ignorance. Cheat sheets out of date.
Practices lose revenue to avoidable denials and under-coding while fearing the compliance consequences of over-coding. Each commercial payer has unique pre-auth requirements, coding nuances, and documentation thresholds — and no practice-level view shows which payers generate the most friction.
Payer knowledge, systematized
A quarterly-updated, payer-specific rules engine surfaces each payer's requirements at the point of coding and pre-auth — the new modifier-25 rule for a specific E/M-plus-procedure combination appears when it matters, so the claim is right the first time. Rules are effective-dated; the billing manager reviews every quarterly update before it goes live.
Suggestions you can defend
Coding suggestions are grounded in the clinical documentation already in the chart — never unsupported codes, with E/M downcodes surfaced alongside upcodes (at least one downcode per three upcode suggestions, by design). Every suggestion, acceptance, and rejection lives in an immutable audit log a compliance officer can query.
Key capabilities
Off by default. Audited always.
Opt-in with disclosure
The practice owner reviews the disclosure, acknowledges the guardrails, and enables at the practice level — timestamp, disclosure version, and enabling user recorded. Gates every other feature in the module.
Payer-specific rules engine
Per-payer documentation requirements, modifier rules, pre-auth triggers, and coding thresholds — surfaced at the point of coding, refreshed quarterly, effective-dated.
Compliant coding suggestions
Documentation-grounded suggestions with original code, suggested code, reason, and compliance flag. Accept or reject; the disposition is logged either way.
E/M downcode surfacing
When the documentation supports a lower level than selected, the downcode appears — balanced guidance that protects against systematic over-coding audit risk.
ROI dashboard
Denial-rate trends by payer, suggestion acceptance rates, payer-mix composition over time, and the net impact of optimization actions. Aggregate data only; no per-patient margins.
Advisory scheduling guidance
Payer-aware slot guidance that considers payer-mix targets — advisory only, with the scheduler always holding final say and three hard guardrails enforced in the engine.
Compliance audit log
Every configuration change, suggestion, disposition, and rule update recorded with actor, action, patient, detail, and timestamp. Immune to soft-delete.
Quarterly payer-rules updates
New policies, documentation requirements, and modifier rules arrive each quarter; prior rule sets retire with full version history.
Denial-pattern detection
Where denials cluster — by payer, by code, by documentation gap — the dashboard shows it, and the rules engine learns from it.
Guardrails
The lines this module will not cross.
Never reduce Medicare/Medicaid access
Scheduling guidance will never deprioritize, limit, or discourage appointments for Medicare or Medicaid beneficiaries. A hard rule in the engine, not a setting.
Never discriminate on protected categories
Race, ethnicity, gender, protected age, disability status — never factors in scheduling or coding suggestions. Enforced at the rules-engine level.
Never show payer margin to patients
The patient-facing experience is identical whether the module is enabled or not. Zero instances, zero exceptions.
Never suggest an unsupported code
Any unsupported suggestion is a defect, not a metric to optimize. The target is 0%.
Never the moat
The platform's competitive moat is the longitudinal patient record and the clinical workflow — payer navigation is a feature, deliberately bounded.
Who benefits
Enables or disables at will, reads the ROI dashboard, sees aggregate trends — never per-patient margins.
Payer knowledge codified instead of locked in staff memory; quarterly updates reviewed before go-live.
One-click accept/reject on suggestions with confidence they're clinically supported — and an audit trail that protects them.
Can query every suggestion and disposition to demonstrate the engine never proposed an unsupported code — and surfaced downcodes too.
Performance targets
The numbers this module is built to hit.
| Metric | Target |
|---|---|
| Avoidable-denial reduction within 90 days of opt-in | ≥ 15% |
| Unsupported-code suggestions | 0% — ever |
| Downcodes surfaced per upcode suggestions | ≥ 1 per 3 |
| Coding suggestion acceptance band | 30–70% — balancing utility against automation bias |
| Medicare/Medicaid access reduction incidents | 0 — hard guardrail |
| Payer-margin data shown to patients | 0 — hard guardrail |
| Optimization actions captured in the audit log | 100% |
Standards & the compliance frame
The law it's built around.
False Claims Act exposure is the reason for the construction: 0% tolerance for unsupported code suggestions, the 3:1 upcode-to-downcode balance enforced in the rules engine rather than configuration, and recorded opt-in disclosure that a compliance officer can query at any time.
Connected modules
A consumer of the platform, not a power unto itself.
Coding & CDS
Suggestions are generated by rules authored and versioned in the CDS module — this module consumes, never authors.
Module 04 →Revenue Cycle
Denial data feeds the ROI dashboard; accepted suggestions flow into charge capture.
Module 07 →Scheduling
Advisory slot guidance integrates with the scheduler — which always owns the appointment.
Module 02 →Compliant by construction.
Payer intelligence with guardrails your compliance officer will actually like.
Join the waitlist