The problem
A multi-location US medical practice with 12 providers was spending over 40 staff-hours per week on medical billing — reviewing encounter notes, assigning CPT and ICD-10 codes, submitting claims to payers, and manually chasing denials. Billing staff turnover was high because the work was repetitive and error-prone. Denial rates were running at 14%, well above the 5–8% industry benchmark.
The automation pipeline we built
1
EHR integration & encounter ingestion
n8n workflow triggers on new encounter completion in the EHR (Epic FHIR API). Encounter notes, diagnoses, procedures, and patient data pulled and structured. HIPAA-compliant data handling throughout — all processing within a private AWS VPC, encrypted at rest and in transit.
2
AI auto-coding engine
A fine-tuned LLM reads the encounter note and recommends CPT codes, ICD-10 diagnosis codes, and modifiers with confidence scores. Trained on 3 years of the practice's own historical coding decisions — the model learns their specific patterns, not just generic coding rules.
3
Payer rules validation layer
Before submission, a rules engine cross-checks the codes against each payer's specific coverage policies, bundling rules, and prior authorisation requirements. Common denial patterns caught proactively — the system flags 87% of would-be denials before the claim is submitted.
4
Human review queue for edge cases
Claims with confidence below threshold, unusual procedure combinations, or payer flags are routed to a reviewer queue in the Django web app. Reviewers see the AI's recommendation, its reasoning, and relevant payer policy — approving or correcting in seconds rather than minutes.
5
Automated denial management
When a claim is denied, an n8n workflow classifies the denial reason, determines if an appeal is viable, drafts the appeal letter using an LLM, and routes for one-click submission. Denial follow-up cycle reduced from 3 weeks to 4 days average.
Our billing team went from spending all day coding and chasing denials to reviewing edge cases for 2 hours a day. Our denial rate dropped from 14% to 6.2% in the first 90 days. The ROI was clear within the first billing cycle.
— Practice Administrator, Multi-location Medical Group, Texas
