Cofactor AI Denials Suite is an AI-driven platform designed to automate and streamline the complex insurance denial appeal process for healthcare providers, particularly focusing on retroactive denials, audits, DRG downgrades, and clinical necessity denials.
Product Overview and Key Benefits The platform acts as a "value capture engine" to address critical bottlenecks in inpatient hospital billing and revenue cycle management (RCM). By leveraging a proprietary medical-native foundation model, Cofactor AI reviews clinical evidence, coding guidelines, standard of care guidelines, and peer-reviewed studies to identify discrepancies between claims, medical documentation, payer policies, and facility contracts. This process significantly reduces the time and manual effort required for denial management, allowing an individual team member to prioritize, review, and appeal a denial in a few minutes, compared to the hours it might take manually. The key outcomes are improved overturn rates, recovery of lost revenue, and surfacing root cause insights to prevent future denials.
Main Features and Capabilities
- AI-Powered Appeal Generation: Instantly generates appeal letters tailored to each case, backed by clinical evidence and legal requirements.
- Discrepancy Identification: Automatically identifies mismatches between claims, documentation, payer policies, and provider contracts.
- EHR and Clearinghouse Integration: Seamlessly integrates with existing systems to extract relevant data for appeal generation.
- Claim Prioritization: Prioritizes denied claims based on urgency and value.
- Root Cause Analysis: Provides insights into what is driving denials, enabling proactive prevention.
- Human-in-the-Loop Workflow: The AI generates the appeal, which is then reviewed by a human before being sent to the insurance company.
Target Users and Use Cases The primary target users are revenue cycle management teams within Hospitals and Health Systems. Use cases include fighting DRG downgrades, readmission denials, clinical necessity denials, RAC audits, and retrospective reviews to transform denied claims into approved reimbursements.
