# Deterministic Agentic AI for Healthcare Operations | Kognitos > Deterministic agentic AI that automates claims management, prior authorization, billing, and eligibility for healthcare teams — with neurosymbolic architecture that guarantees hallucination-free results. HIPAA-compliant, SOC 2 certified, governed by design. ## The Problem Your revenue cycle is bleeding margin. Here's what it's costing you. - **$5M+** lost to denied claims annually — Up to 90% of denials are preventable. Most tools catch issues after the fact, not before submission. - **3–5 days** wasted per prior authorization — Patients wait, procedures get delayed, and revenue sits in limbo while staff chase payer portals and fax machines. - **4 vendors** for one revenue cycle — Denial management, prior auth, eligibility, billing — each from a different vendor with its own data model, contract, and integration headache. Plus: your best biller retires and takes 20 years of payer-specific nuance with them. Every new mandate means a six-month IT project. And HIPAA compliance is bolted on, not built in. --- ## The Solution Revenue cycle teams already fixed this. They automated claims, prior auth, and billing on Kognitos — and went live in hours, not months. HIPAA-compliant, zero hallucinations, governed end-to-end. | Metric | Before | With Kognitos | |--------|--------|---------------| | Prior auth turnaround | 3–5 days | **4 hours** | | Claims auto-resubmission | $5M+ lost | **91%** | | Recovered annually per facility | 70% manual | **$2.1M+** | | Time to deploy | Months | **Hours** | Named a Sample Vendor in the Gartner Hype Cycle for AI in Finance, 2025. Trusted across regulated industries including healthcare. --- ## Live Healthcare Apps Production-grade healthcare apps built in hours. Try them now. Each app was designed on the Kognitos platform. Scalable database, governed workflows, RBAC, audit trails, and exception handling — all production-ready and HIPAA-compliant. ### 1. Provider Claims Processor Automates the provider billing workflow from charge capture through claim submission and payment posting. Tracks claim status, identifies underpayments, and accelerates revenue collection across payers. ``` Match claim to encounter by patient ID and DOS. If billed amount > allowed amount, flag as underpayment. Route to collections if unpaid after 30 days. ``` - End-to-end provider billing automation - Payment posting and reconciliation - **Results:** 60% reduction in billing cycle time, 3x faster claim resolution ### 2. Payer Claims Analysis Provides payer-side claims analytics and review. Analyzes claims patterns, validates medical necessity, identifies fraud indicators, and generates compliance reports for regulatory submissions. ``` For each claim in batch: Validate medical necessity against payer policy. If documentation missing, request from provider. Flag fraud indicators exceeding threshold. ``` - Claims pattern analysis across providers - Fraud and abuse indicator detection - **Results:** 40% faster claims adjudication, 25% reduction in improper payments ### 3. 340B Discount Eligibility Check Automates HRSA 340B program eligibility verification using the 6-factor test. Validates patient encounters, provider status, and prescription data to ensure compliant 340B pricing — reducing audit risk and manual review time. ``` Check patient against HRSA 6-factor test. If encounter qualifies AND provider is registered, approve for 340B pricing. Log decision with full audit trail. ``` - Automated HRSA 6-factor eligibility check - Audit-ready documentation and run history - **Results:** 85% reduction in manual eligibility review, 99% audit compliance accuracy ### 4. Patient Referral Processing Automates the referral intake workflow — capturing referral details, validating insurance and authorization, matching patients to specialists, and routing with complete clinical context for faster scheduling. ``` Extract referral details from incoming fax. Verify insurance and authorization status. Match to specialist by specialty, location, and availability. ``` - Referral intake and data extraction - Specialist matching and scheduling - **Results:** 70% reduction in referral processing time, 50% fewer referral-related delays ### 5. Patient Call Records Analysis Retrieves patient call records from SharePoint, analyzes interactions including medications and ER visits, generates comprehensive reports with visual timelines, and sends formatted summaries to Teams. ``` Retrieve patient call records from SharePoint. Analyze for medication changes and ER visits. Generate timeline report and send summary to Teams. ``` - Automated call record retrieval from SharePoint - Visual timeline and report generation - **Results:** 80% reduction in manual record review, 5min from call data to Teams summary These apps were each designed in hours on the Kognitos platform. Your workflows are different — describe them in plain English and Kognitos builds a production-grade app with governance, audit, and scale built in. --- ## Why One Platform Beats Four Point Solutions | Dimension | Point Solutions | Kognitos | |-----------|----------------|----------| | Implementation | Months per tool | Hours | | Maintenance | Per-tool dev teams | Zero-code, self-healing | | Auditability | Varies by tool | Every step in plain English | | Exceptions | Manual escalation | Auto-encoded by AI | | Hallucination risk | Probabilistic AI | 0% — by architecture | | Who defines it | Developers / IT | RCM leaders + tech teams | | Data silos | One per tool | Unified data layer | | Total cost | 4× vendor stack | Single platform | Covers Claims, Prior Auth, Billing, Eligibility, Patient Intake, and Compliance. --- ## Customer Results ### Fortune 200 Enterprise Manual compliance evidence collection consumed thousands of hours each quarter across regulated operations. **97% reduction in audit time.** Evidence collection fully automated — from thousands of hours to continuous monitoring. ### Wesfarmers Finance automation blocked by manual processes across 200+ countries in a highly regulated environment. **92K hrs saved annually** across finance automation. The same engine that powers healthcare workflows. ### Scan Health Plan Edge cases escalated manually, slowing resolution across claims and compliance workflows. **5x faster exception resolution.** Every edge case encoded into deterministic logic, governed and HIPAA-compliant. --- ## Integrations 130+ pre-built integrations connecting to the systems your healthcare org already uses. **EHR & Practice Management:** Epic, Oracle Health, Athenahealth, MEDITECH **Clearinghouses & Payers:** Availity, Waystar, Change Healthcare **ERP & Financials:** SAP, Workday, NetSuite, Dynamics **Cloud & Data:** AWS, Azure, GCP, Snowflake, Databricks **Collaboration & Workflow:** Salesforce, ServiceNow, Microsoft 365, Slack, SharePoint, Box, Google Workspace, Veeva [View all integrations →](https://www.kognitos.com/integrations/) --- ## Security & Compliance - **SOC 2 Type II** — Independently audited security controls across availability, confidentiality, and processing integrity - **HIPAA Compliant** — Full PHI handling with audit trails, access controls, and data processing agreements - **GDPR Ready** — Data residency controls, right-to-erasure support, and full processing transparency - **RBAC & Governance** — Role-based access controls on who can run, modify, approve, and audit automations --- ## FAQ **How can AI automate claims denial management?** AI automates claims denial management by detecting denial patterns, categorizing root causes, assembling supporting documentation, and auto-resubmitting corrected claims within payer deadlines. Kognitos's Claims Lifecycle Manager uses English-as-Code rules to monitor remittance files, identify actionable denials, match to payer-specific resubmission requirements, and route appeals with full context — recovering revenue that would otherwise be written off. **What is agentic AI in healthcare?** Agentic AI in healthcare refers to autonomous software that can perceive, decide, act, and adapt within healthcare workflows — from claims processing to prior authorization to patient intake. Unlike traditional RPA, agentic AI handles exceptions, learns from human guidance, and executes multi-step processes. Kognitos ships pre-built healthcare workflows and lets teams build unlimited more in plain English — all executed deterministically with zero hallucinations. **How does Kognitos ensure HIPAA compliance?** Kognitos is HIPAA-compliant by design: full PHI handling with end-to-end encryption, granular role-based access controls, comprehensive audit trails logging every action, and signed Business Associate Agreements. The platform is also SOC 2 Type II certified. **How does Kognitos eliminate hallucinations in healthcare automation?** Healthcare cannot tolerate AI improvisation. Kognitos uses a patented neurosymbolic architecture that separates intent interpretation from execution. An LLM understands your business rules written in plain English, but a deterministic Symbolic Executor handles all execution. It cannot improvise, cannot hallucinate, and every variable is recorded. **How does Kognitos handle exceptions in healthcare workflows?** When an automation encounters an exception — a claim with missing data, an auth request that doesn't match payer rules, an eligibility check with conflicting results — Kognitos routes the issue with full context and a suggested resolution. Once a human resolves it, the platform permanently encodes that fix into its deterministic logic. Over time, 90%+ of exceptions auto-resolve. **Can revenue cycle teams build automations without coding?** Yes. English-as-Code means plain English instructions are the actual executable code. A revenue cycle director can write business rules and the platform compiles and executes them deterministically. Pre-built healthcare workflows ship ready to deploy — no developers required. --- [Book a Demo](https://www.kognitos.com/book-a-demo/) | [Try It Free](https://app.us-1.kognitos.com/) | [Platform Overview](https://www.kognitos.com/platform/)