Home health ADR, denial and appeal work, handled inside your agency
Home health ADRs and denials are revenue-cycle work most agencies still do by hand. Our AI agents read, route and assemble each response; our experts set the rules and take the judgment calls.
Denials, ADRs and appeals, in the order our study ranks them for automation
- Denial, return and review routing and triageIn the top ten of 169 workflowsWorth it, ready now
- Certification and face-to-face denialsIn the top 25 of 169 workflowsWorth it, ready now
- Assessment, notice and edit returnsIn the top 25 of 169 workflowsWorth it, ready now
- Hospice level-of-care and election denialsIn the top 25 of 169 workflowsWorth it, ready now
- Medical-necessity, homebound, skilled-need and terminal-prognosis denialsIn the top half of 169 workflows
- Denial and return intake from the remittance and the federal systemIn the top half of 169 workflowsWorth it, ready now
- Documentation request and audit response assemblyIn the top half of 169 workflows
- Appeal letter compositionIn the top half of 169 workflows
- Coordination-of-benefits, duplicate and timely-filing denialsIn the top half of 169 workflowsWorth it, ready now
- Additional documentation request, targeted probe and audit letter intakeIn the top half of 169 workflows
- Appeal submission and follow-up cadence across the five Medicare appeal levels and plan appealsIn the lower half of 169 workflowsWorth it, ready now
Denials age in queues while the clocks run out
Every denial, returned claim and audit letter carries a deadline, and in most agencies a person reads each one by hand.
Deadlines decided by hand
One or two senior billers decide the path for every denial, and the whole queue waits on them.
Late ADRs are lost
Late or missing response to additional documentation request automatically denies claim.
The appeal nobody files
Medical-necessity rebuttals and rebills miss appeal windows while staff do urgent work.
The denial work we take off your billers
Four workflows where denials and ADRs move the day they land, each with a named owner and a held deadline.
Every denial takes the right path the day it lands
In most agencies one senior biller reads every denial and picks its path from memory. Our AI agents sort each one against your payer rules the day it posts; our experts take what the rules cannot place.
- Every denial carries its path and its owner
- Appeals filed inside the payer window, every time
- No denial sits between two desks unnamed
Fix the record, keep the certification claim
Home health requires a face-to-face encounter within 90 days before or 30 days after start of care. Our AI agents match each denial to the encounter note and prepare the fix or appeal; our experts review it.
- Every certification denial traced to its missing element
- Corrections drafted from the record
- Appeals carry the encounter and certification evidence attached
Returned claims corrected in bulk, and the rule fixed upstream
Late notice penalties and unaccepted assessments are fixed one claim at a time today. Our AI agents correct every return at its root and request penalty exceptions where the cause qualifies; our experts handle the rest.
- Each return traced to its edit
- Penalty exceptions requested wherever the cause qualifies
- The same edit does not recur
How the work runs inside your agency
Our engineers work with your billing, intake, clinical teams, building for workflows, payer mix, and systems, the same method.
01Your team brings the work
You bring the denial and ADR work that costs you most, plus your payer mix and systems. Your EMR, clearinghouse and payer portals stay where they are.
02Our experts map and fix the data
Our engineers sit with your billing team, watch the workflow as it runs, and fix the data it depends on before anything is automated.
03Our AI agents take the work
Our experts set the rules, written where your staff can change them, then release our AI agents into the live workflow. Your team reviews what they flag.
How custom AI built inside your agency beats the usual answers
Your agency is comparing us against software, the EMR's billing module and an outsourced billing shop. Here is the honest line on each, and on us.
Custom AI built inside your agency
Our engineers sit inside your operation, building for your denial work, your payer mix and your systems. Our AI agents run beside your EMR and payer portals, and your staff make the call.
- Built around your payer mix
- Your staff can see and change every rule
- Priced by workflows automated, headcount stays free
Billing and RCM software
Good at running the same checked steps for every agency; most stop at flagging, and the queue still waits on a person.*
Your EMR's billing module
Good at holding the claim and the record in one place; edits and appeals usually stay manual work.*
An outsourced billing company
Steady hands on the queue; your rules and findings usually live in their shop, waiting outside your workflows.*
* These describe each category as commonly sold; your vendor's terms, scope and results will differ. Terms, scope and results vary by company and contract.
Your staff decide, your systems stay, and you pay by workflow
How is this priced?
A fee plus a part tied to outcomes; each workflow automated carries a set price. When we automate another workflow, the number moves; adding people to the review never does.
Do we have to replace our EMR?
No. Our AI agents run beside your existing EMR, clearinghouse and payer portals, and your agency keeps its data. Nothing you use today is replaced.
Who makes the calls on a denial?
Your staff make the calls. Our AI agents read, route and draft; they make no clinical decisions and never send an appeal your team has not reviewed.
What do we need to have ready?
Nothing new to buy or prepare. Our experts need time with your billing team and a look at how the denial work runs today; patient data never leaves your systems.
Your denials stop aging in someone's queue
A conversation about one workflow, no patient data. You name the denial or ADR work that costs your agency most; we say what our AI agents would take over.
Common questions
What is an ADR for home health services?
An ADR for home health is a Medicare medical review contractor asking for the records behind a claim. It carries a 45-calendar-day response clock, and a late or missing response is an automatic denial.
What is an ADR letter in Medicare?
An ADR letter in Medicare is a review contractor asking for the record behind a chosen claim. It starts a 45-calendar-day clock; our AI agents log it the day it arrives.
Does home health require a face-to-face?
Yes. Home health requires a face-to-face encounter within 90 days before or 30 days after the start of care. A missing one can cost the agency the period.
How to appeal medical necessity denials?
Rebut the denial against the coverage criteria with the record cited: the assessment, the visit notes and the decline evidence. Our AI agents draft that rebuttal; your clinical manager approves it.
How to appeal Medicare Advantage plan denial?
File the plan's own appeal with the record behind the visits attached, then track it through the plan's levels. Our AI agents carry each case and place the status calls.
How to show proof of timely filing?
An electronic claim sent by 5:00 p.m. in the contractor's time zone to its contracted clearinghouse counts as received that day, and that date governs timely filing.
How many times can you appeal a Medicare denial?
Medicare fee-for-service denials can be appealed through five levels, starting with redetermination and reconsideration. Most cases settle in the first two; our AI agents hold each level's deadline.
The full study, PDF · 636 KB
Take the documentation fights once the plumbing works
The highest-value work left on the table is hard for honest reasons: the data is messy and the rules bend to the patient in front of you.