Afrexai Medical Billing

# Medical Billing & Revenue Cycle Management

Analyze medical billing workflows, identify revenue leaks, optimize claim submissions, and reduce denial rates. Built for healthcare practices, billing companies, and revenue cycle teams.

## What This Covers

### CPT/ICD-10 Coding Accuracy
- Common coding errors by specialty (top 10 per specialty)
- Modifier usage: 25, 59, 76, 77, AI, AS — when required vs when it triggers audit
- E/M level selection (2021 guidelines): time-based vs MDM-based
- Evaluation matrix: does documentation support the code billed?

### Claim Denial Analysis
- Denial reason code lookup (CARC/RARC codes)
- Top 20 denial reasons across commercial + Medicare + Medicaid
- Root cause mapping: front-desk error, coding error, clinical documentation, payer policy
- Appeal letter framework by denial type (with timelines)
- Clean claim rate benchmark: 95%+ target

### Revenue Cycle KPIs
| Metric | Target | Red Flag |
|--------|--------|----------|
| Days in A/R | <35 | >50 |
| Clean claim rate | >95% | <90% |
| First-pass resolution | >90% | <80% |
| Denial rate | <5% | >10% |
| Collection rate | >95% | <90% |
| Cost to collect | <4% | >7% |
| Net collection rate | >96% | <92% |

### Payer Contract Analysis
- Fee schedule comparison: Medicare vs commercial rates by CPT
- Allowed amount benchmarking (what you should be getting paid)
- Underpayment detection: compare ERA/835 to contracted rates
- Rate negotiation prep: volume data, market rates, quality metrics

### Compliance & Audit Readiness
- OIG Work Plan items relevant to your specialty
- Stark Law / Anti-Kickback safe harbors checklist
- False Claims Act risk factors
- Internal audit sampling methodology (statistically valid)
- Documentation improvement programs (CDI)

### Charge Capture Optimization
- Missed charge identification by department
- Charge lag analysis (days from service to charge entry)
- Superbill/encounter form design best practices
- Common missed revenue: vaccines, injections, supp...

# Medical Billing & Revenue Cycle Management

AI agent skill for medical billing analysis, claim denial management, revenue cycle optimization, and healthcare compliance.

## Features

- **CPT/ICD-10 coding accuracy** — error detection, modifier guidance, E/M level validation
- **Denial analysis** — CARC/RARC code lookup, root cause mapping, appeal letter templates
- **Revenue cycle KPIs** — days in A/R, clean claim rate, denial rate, collection benchmarks
- **Payer contract analysis** — fee schedule comparison, underpayment detection, negotiation prep
- **Compliance** — OIG Work Plan, Stark Law, False Claims Act, audit readiness
- **Charge capture** — missed charges, lag analysis, superbill optimization
- **Patient responsibility** — eligibility verification, prior auth, No Surprises Act compliance

## Who This Is For

- Medical practices (any specialty)
- Revenue cycle management companies
- Healthcare billing departments
- Practice management consultants
- Healthcare IT teams building billing automation

## Quick Start

Install this skill in your AI agent (OpenClaw, Claude, etc.) and ask:

```
Our family medicine practice has 45 days in A/R and an 8% denial rate.
Payer mix: 40% Medicare, 30% commercial, 20% Medicaid, 10% self-pay.
What should we fix first?
```

## More Healthcare AI Tools

Get the complete Healthcare AI Context Pack — 50+ frameworks covering billing, compliance, clinical operations, and patient experience optimization.

**[Browse all context packs →](https://afrexai-cto.github.io/context-packs/)**

- Healthcare Pack — $47
- Pick any 3 packs — $97
- All 10 industry packs — $197

**[Free AI Revenue Calculator →](https://afrexai-cto.github.io/ai-revenue-calculator/)** — Find out how much revenue your practice is losing to manual processes.

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Built by [AfrexAI](https://afrexai-cto.github.io/context-packs/)