Stop losing revenue to preventable eligibility & PA errors
👉 Request a SmartOps Demo Let’s protect revenue, teams, and compliance - together.SmartOps RCM Intelligence
Designed for RCM leaders handling 5,000+ claims/month
AI Agent For Healthcare
For Healthcare - Medical Service Providers: Governed AI for Insurance Claim Eligibility, Authorization & Denial Prevention
Healthcare Service Providers – move away from reactive and manual revenue recovery process to an intelligent, governed and assured revenue RCM (Revenue Cycle Management) model that reduces claim denials and manual processing.
Reduce preventable claims denials before billing and claims are submitted – without disrupting your RCM team.
Current RCM Frustrations
Before
After
Revenue leakage is happening before claims even reach the payer
- Eligibility checks show “Active” in portal – but claims still get denied
- Contract rules (eg. co-pay, exclusions) buried in PDFs and portals
- Prior Authorization mistakes discovered after submission
- Teams rely on memory, judgment, and manual checks
- Audit queries arrive months later – with no defensible trail
Result:
❌ 10 -15% OPD denials
❌ High admin rework, burnout, and escalations
❌ Revenue loss CFOs can’t predict or control
From reactive RCM → Pre-submission intelligence SmartOps RCM Intelligence works before money is at risk – during Eligibility and Prior Authorization. It does not replace your systems or staff. It augments them with contract-driven intelligence and audit safety. ✅ 90–95% clean submissions with denials prevented before filing
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What is SmartOps RCM Intelligence?
A governed AI layer that sits above your RCM workflow
SmartOps RCM Intelligence combines:
- Policy-as-Code rules mapped to payer contracts
- AI intelligence to explain risk and ambiguity
- Human-in-the-loop approvals for accountability
- Audit-ready evidence for payer defense
✔️ No auto-rejections
✔️ No black-box decisions
✔️ No disruption to existing HIS / EMR
How it Works
Eligibility & PA Intake
→ SmartOps RCM reads demographics, intent, and policy context from payer portal
→ Deterministic rules enforce demography and contract eligibility checks
→ AI explains risk, gaps, and exposure
→ Human (RCM team) approves or resolves
→ Clean, defensible submission
Core Capabilities
Eligibility Verification Intelligence
Bot reviews demography and contract from portal (API/RPA); Goes beyond “Active Coverage” Detects: • Waiting periods • Benefit exhaustion • Exclusions • Partial coverage Captures decision context for audits .
Contract-Driven Rules Engine
Rules are mapped directly to: • Payer contracts • Plans (Prestige / Privilege / VIP) • Employee tiers Fully versioned, testable, auditable No generic assumptions
AI That Explains - Not Decides
Highlights denial risk Explains why a case is risky Suggests corrective actions Always routes decisions to humans
Audit & Governance by Design
Every decision captures: • Rule triggered • Contract clause referenced • User action taken Built for payer audits and compliance reviews
Who is it for?
- Clinics & hospitals (OPD-heavy and with high claim rejection rates)
- 6,000+ monthly insurance claims
- Multiple payers & plans
- High eligibility & PA complexity
- CFO-driven revenue accountability
Ideal for:
RCM Heads • CFOs • COOs • Revenue Integrity Teams
Real Business impack
Typical SmartOps RCM Intelligence customers see:
- 📉 30% reduction in denied claim volume
- ⏱️ 35% time savings
- 🧠 Less dependency on individual staff memory
- 🛡️ Strong audit and payer defensibility
- 💰 Clear visibility into revenue at risk