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AI agent for medical billers

Edit Rule Update Impact Agent

New edit rules are tested before they hit live claims, and the scrubber is updated before denials rise.

Risk managementQuality controlHealthcare
See how it worksGet access
Edit Rule Update Impact Agent: what goes in, what the agent does and what you get

What it does

Each quarter, bundling edits change what can be billed together, and denials spike a month later. The agent compares the new edit tables with the old, finds code pairs the practice bills often, and tests recent claims for new conflicts. It proposes updated rules for the claim scrubber and re-tests them on sample claims to make sure the rules block the right claims and do not block valid ones. The billing lead approves the rule changes. Edge case: a code pair that can still be billed together with a modifier, where the rule must allow it.

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
Yes, continueYes, continueApprovedNoNo 1 STARTS WHEN New quarterly edit tables published 2 USES A TOOL Compare the new tables with the old 3 DOES List new or changed code pairs 4 DOES Rank them by how often the practice bills them 5 USES A TOOL Test recent claims for new conflicts 6 CHECKS THE RESULT Do the conflicts match the changes in the tables? If not: Recheck the table version and rerun the test.Back to step 4. 7 DOES Draft scrubber rule changes 8 USES A TOOL Retest the new rules on sample claims 9 CHECKS THE RESULT Do the rules block bad claims without blocking validones? If not: Adjust the rule and retest. Back to step 6. 10 YOU APPROVE Billing lead approves the rule changes 11 RESULT Rule update and test report
Read the steps as a list
  1. New quarterly edit tables published
  2. Compare the new tables with the old
  3. List new or changed code pairs
  4. Rank them by how often the practice bills them
  5. Test recent claims for new conflicts
  6. Do the conflicts match the changes in the tables?If not: Recheck the table version and rerun the test. Back to step 4.
  7. Draft scrubber rule changes
  8. Retest the new rules on sample claims
  9. Do the rules block bad claims without blocking valid ones?If not: Adjust the rule and retest. Back to step 6.
  10. Billing lead approves the rule changesThe agent waits here for your OK.
  11. Rule update and test report

How it decides

It ranks changed code pairs by how often the practice bills them and tests each new rule on past claims before proposing it.

  • Prioritize pairs billed more than 50 times a quarter
  • Allow pairs that are valid with a modifier
  • Test on at least 100 recent claims
  • Apply updates before the quarter starts

Make it yours

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

  • Quarter start dates
  • Billing frequency threshold (default 50)
  • Test sample size (default 100)
  • Payers covered

What keeps you in control

It always asks you first

  • Billing lead approves every rule change before it goes live

Hard limits

  • Never change scrubber rules without approval
  • Test before any rule goes live

It stops when

  • Done: updated rules tested and approved
  • Stop: edit table source is unclear and the billing lead must confirm

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 new table bundles 3 code pairs the practice bills about 400 times a year. Testing on 120 recent claims shows 26 would now deny. The first draft rule also blocks 4 valid claims that carry modifier 59, so the check fails. The agent adjusts to allow the modifier and retests. The billing lead approves the final rules.

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