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Introduction

RCM (Revenue Cycle Management) is a comprehensive healthcare billing platform that uses AI to optimize claim processing, reduce denials, and maximize revenue recovery.

Overview​

The RCM platform helps healthcare organizations manage the complete revenue cycle - from claim submission through payment collection. By integrating AI assistants through the Model Context Protocol (MCP), it transforms complex billing workflows into conversational interactions.

What Problems Does It Solve?​

1. Denial Management​

Healthcare providers lose billions annually to claim denials. RCM provides:

  • Instant denial classification - Understand why claims were denied
  • AI-powered recommendations - Know whether to appeal, rebill, or write off
  • Pattern detection - Identify systemic issues causing repeated denials

2. Cash Leakage​

Money slips through the cracks when denials aren't worked properly. RCM helps:

  • Identify revenue loss patterns - Group denials by category, payer, or code
  • Calculate recovery potential - Know which denials are worth pursuing
  • Prioritize work - Focus staff time on high-value opportunities

3. Preventable Denials​

Many denials can be prevented with better processes. RCM enables:

  • Pre-submission validation - Catch coding errors before claims are sent
  • Automated rule checking - Verify modifiers, diagnosis support, and NCCI edits
  • Policy compliance - Ensure claims meet payer requirements

4. Manual Research Time​

Billing staff spend hours looking up denial codes and policies. RCM provides:

  • Conversational access to denial code libraries and payer policies
  • Instant recommendations based on organization rules
  • Natural language queries instead of complex database searches

Platform Components​

RCM is organized as a monorepo containing four main packages:

MCP Server​

AI-powered revenue cycle management tools accessible through the Model Context Protocol:

  • 24 specialized tools for denial triage, appeals, write-offs, and analytics
  • Works with any AI assistant that supports MCP
  • Can run with PostgreSQL or in-memory mode

Database Migrations​

PostgreSQL schema with comprehensive RCM data model:

  • 10 tables tracking claims, denials, appeals, and financial workflows
  • Seeded reference data (denial codes, policies, coding rules)
  • Complete audit trail for compliance

Infrastructure​

AWS CDK templates for production deployment:

  • RDS PostgreSQL database
  • VPC networking and security
  • S3 document storage

Shared Types​

TypeScript schemas and validation:

  • Zod runtime validation
  • Shared across all packages
  • Type-safe API contracts

How It Works​

  1. Ask Questions - Billing staff asks AI assistant about denials, appeals, or coding issues
  2. AI Uses Tools - Assistant calls MCP server tools to access RCM data and logic
  3. Get Recommendations - AI provides specific, policy-driven recommendations
  4. Take Action - Staff follows guidance to appeal, rebill, or write off claims

Example Interaction​

Staff: "We got a CO-197 denial for $450. What should we do?"

AI Assistant:

This is an authorization denial (CO-197). Your policy says to appeal all authorization denials over $250.

Recommended Action: Appeal (High Priority)

  • Amount: $450 exceeds $250 threshold
  • Success rate: 65% for authorization denials
  • Next steps: Gather authorization documentation, file within 15 days

Next Steps​