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AI agent for occupational therapists

Documentation Audit Agent for Medical Necessity

Notes show medical necessity and the pass rate rises month by month.

ComplianceQuality controlHealthcare
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Documentation Audit Agent for Medical Necessity: what goes in, what the agent does and what you get

What it does

Payers deny claims when notes do not show findings, goals and progress. The agent takes a monthly sample of visit notes and checks each for the elements the payer expects: objective findings, a functional goal, a link between treatment and goal and a statement of progress. It scores each note, flags the weak ones with the exact gap, and drafts specific feedback for the clinician. After the clinician corrects a note, it checks again. If the corrected note still lacks a goal or progress statement, it sends it back with the specific gap named. It tracks the pass rate by clinician over time. The clinician approves any change to a note. Edge case: a note that was already billed needs an addendum, not a rewrite.

How it works

Follow the arrows from top to bottom. The orange dashed arrow is the loop: when a check fails, the agent goes back and tries again.

Start and resultWhat it doesA check on its own workWaits for your OKGoes back and retries
ApprovedYes, continueYes, continueNoNo 1 STARTS WHEN Monthly sample 2 USES A TOOL Pull a sample of notes and billing status 3 DOES Check each note for findings, goal, treatment linkand progress 4 DOES Score the note and list gaps 5 DOES Draft feedback for the clinician 6 YOU APPROVE Clinician reviews the feedback and corrects the note 7 USES A TOOL Read the corrected notes 8 CHECKS THE RESULT Does the corrected note now show all requiredelements? If not: Send it back to the clinician with the specificgap named. Back to step 3. 9 DOES Update pass rates by clinician 10 CHECKS THE RESULT Is the pass rate above the target? If not: Draft a short training topic for the weakestelements. Back to step 3. 11 RESULT Audit report
Read the steps as a list
  1. Monthly sample
  2. Pull a sample of notes and billing status
  3. Check each note for findings, goal, treatment link and progress
  4. Score the note and list gaps
  5. Draft feedback for the clinician
  6. Clinician reviews the feedback and corrects the noteThe agent waits here for your OK.
  7. Read the corrected notes
  8. Does the corrected note now show all required elements?If not: Send it back to the clinician with the specific gap named. Back to step 3.
  9. Update pass rates by clinician
  10. Is the pass rate above the target?If not: Draft a short training topic for the weakest elements. Back to step 3.
  11. Audit report

How it decides

It checks each note for the required elements and returns the specific missing item to the clinician.

  • Missing goal or progress statement fails the note
  • Billed notes get an addendum, not a rewrite
  • Sample at least 10 notes per clinician
  • A pass rate below 90% triggers training

Make it yours

Every agent is a starting point. You choose these settings for your own situation.

  • Sample size
  • Required note elements
  • Pass rate target (default 90%)
  • Payer rule set
  • Audit frequency

What keeps you in control

It always asks you first

  • Clinician approves any change to a note
  • Clinic lead approves training plans

Hard limits

  • Never edit a clinical note
  • Never alter a billed record without an addendum
  • Never judge care quality, only documentation

It stops when

  • Done: all sampled notes pass and the report is filed
  • Stop: the payer rules change and the checklist must be updated

Set it up

We guide you through the set-up, step by step

Members get the full set-up guide for this agent. No technical skills needed: you copy, paste and upload.

10 minto set it up in your AI
5 AIsChatGPT, Claude, Copilot, Gemini, Grok
  • One set of instructions to paste into your AI, with the clicks for ChatGPT, Claude, Microsoft 365 Copilot, Gemini and Grok
  • The agent then walks you through connecting your own data, one source at a time
  • A downloadable copy with the flow chart, the rules and the full guide
Get access to this agent

An example run

What happensThe agent samples 40 notes and finds 9 with no functional goal and 4 with no progress statement. It drafts feedback. After corrections, 2 notes still lack a goal, so it returns them naming the missing goal. One billed note gets an addendum. The pass rate moves from 68% to 90% after the second pass.

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