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AI agent for medical coders

Overpayment Identification and Refund Agent

Every overpayment is confirmed, tracked against its deadline and returned with an approved explanation.

ComplianceHealthcareInsurance
See how it worksGet access
Overpayment Identification and Refund Agent: what goes in, what the agent does and what you get

What it does

Payments received in error must be found and returned within legal windows, but they hide in remittances. The agent scans payment files for duplicate payments, payments after a denial was reversed, and services that were later recoded, and starts a clock for each case. It verifies each one against the claim file, then drafts the refund request and a plain explanation. It rechecks that the case is not already adjusted, and if it was, it removes the case from the list. It tells the officer how many days remain in each legal window and puts the closest deadlines first. It never repays anything itself. The compliance officer approves any refund. Edge case: an apparent duplicate that is really two separate services on the same day.

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 Remittance batch received 2 USES A TOOL Scan payments for duplicates, reversals and recodes 3 DOES List possible overpayments 4 USES A TOOL Pull the claim file for each 5 CHECKS THE RESULT Is the overpayment confirmed by the file? If not: Close the case as valid and note why. Back tostep 4. 6 DOES Start a deadline clock for each confirmed case 7 USES A TOOL Check whether the amount has already been adjusted 8 CHECKS THE RESULT Is the balance still owed to the payer? If not: Update the case and remove it from the refundlist. Back to step 4. 9 USES A TOOL Draft the refund request and explanation 10 YOU APPROVE Compliance officer approves any refund 11 RESULT Overpayment register
Read the steps as a list
  1. Remittance batch received
  2. Scan payments for duplicates, reversals and recodes
  3. List possible overpayments
  4. Pull the claim file for each
  5. Is the overpayment confirmed by the file?If not: Close the case as valid and note why. Back to step 4.
  6. Start a deadline clock for each confirmed case
  7. Check whether the amount has already been adjusted
  8. Is the balance still owed to the payer?If not: Update the case and remove it from the refund list. Back to step 4.
  9. Draft the refund request and explanation
  10. Compliance officer approves any refundThe agent waits here for your OK.
  11. Overpayment register

How it decides

It flags a payment as a possible overpayment when it exceeds the allowed amount or repeats a paid service, and confirms with the claim file before any refund.

  • Start the clock on the date of identification
  • Alert at 30 days before the legal deadline
  • Check same day services before calling a duplicate
  • Refund only the confirmed amount

Make it yours

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

  • Deadline alert days (default 30)
  • Payers and their rules
  • Types of overpayment to scan
  • Dollar level for review

What keeps you in control

It always asks you first

  • Compliance officer approves every refund and explanation

Hard limits

  • Never issue a refund itself
  • Do not keep disputed funds unrecorded

It stops when

  • Done: refund approved and recorded
  • Stop: legal window may be missed and the officer must decide

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 happensA weekly scan finds 8 possible duplicates. The claim files show 5 are real overpayments totaling $1,860, while 3 are separate services. One of the 5 was already adjusted last week, so the second check removes it. The agent drafts 4 refund requests, and the compliance officer approves them within the 60 day window.

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