Your Automation Is Only as Good as the Fee Schedule It Reads!Your Automation Is Only as Good as the Fee Schedule It Reads!

Last week I wrote about the quiet January problem: Medicare’s conversion factor drops, and every contract pegged to it drops with it. This week is the follow-up, because a lot of people asked the same question. “Fine. How do we stop our teams from drowning in variances?”

The honest answer is automation. But only if you’re automating the right layer.

What we’ve been building

Since launching in December, Medalyze has focused on the two places where RCM teams lose the most hours to repetitive work.

Payment posting. Our payment posting agent now reaches 95% accuracy. It reads remittances, matches payments to claims and posts them, and routes the remaining exceptions to a person instead of burying them in a queue.

Eligibility verification. We’ve built EV calling agents that handle the payer calls front-desk teams dread. Verification gets done before the patient arrives, not after the claim denies.

We’ve also run both, along with billing and claims, across a multi-location practice in Atlanta. Multiple locations are where manual processes break first, because every site does it slightly differently.

And the HRMS you may have seen from us is now Medalyze Flow. It’s the workspace where production work, assignments and client reporting live, so the automation isn’t floating in a separate tool nobody checks.

Why this connects to January

Here’s the part I don’t see discussed. A posting agent doesn’t just post. It compares what was paid against an expected allowable. If the allowables loaded in January are last year’s, a perfectly accurate agent will faithfully flag every Medicare-pegged payer as an underpayer. Accuracy on the task doesn’t rescue bad reference data.

Eligibility has the same January problem. Plan years reset, deductibles start over, and coverage changes hands. Volume spikes exactly when your team is already busy. A call you automate in October is a call you don’t staff in January.

What 95% actually means

I’d rather say this than let someone else say it for me: 95% is not 100%. The remaining 5% is the hard stuff: unusual adjustments, split payments, payer quirks. That’s why exceptions go to humans with context rather than being forced through. If a vendor tells you their automation needs no human review, ask what happens to the claims it can’t read.

Three questions for any RCM automation, ours included

1. What reference data does it depend on, and who updates it when the fee schedule changes?
2. What happens to the cases it can’t handle: logged, routed, or silently dropped?
3. Can you see the exceptions, or only the success rate?

If you want to test ours against your own remits, we’re running a free one-month pilot. Bring your messiest payers.

The practices that do well in January will be the ones that fixed their data in October and automated the rest.

One quiet plumbing problem a week: the CMS deadline, payer behaviour or code change that reaches your claims before it reaches the headlines. Written by Mihir Rajput, Founder & CEO of Medalyze Medtech.