AI agents for medical and dental practices: 6 workflows, explained
From a prior authorization assembled straight from the chart to a denial appealed with the right records: what an AI agent can do for a practice's front office and revenue cycle.
In most practices the clinical work isn't what keeps staff late; it's the administration around it. Prior authorizations, eligibility checks, coding queries, denials and patient balances all mean reading one system and typing into another. An AI agent does that work across the practice management system, payer portals, fax and email, and asks a person before anything is submitted.
Here are the workflows, told through a six-provider orthopedic and physical-therapy practice. In healthcare, agents only run where the practice's privacy and security safeguards are in place, with access limited to what each task needs.
What makes it an agent, not a chatbot
A billing rules engine applies the same edits to every claim. An agent reads the chart, the payer's policy and the denial letter, and does what a skilled coordinator would. Three things set it apart:
2Tomorrow's patients checked overnight: coverage, copays and referrals
If eligibility fails at the desk, the patient waits, the schedule slips and sometimes we see them for free.
Every evening Maria's agent checks each patient on tomorrow's schedule: active coverage, plan changes, copay and deductible remaining, whether a referral or authorization is on file, and missing intake forms. Problems go to the front desk before the patient arrives.
| Patient | Issue | Drafted |
|---|---|---|
| J. Alvarez, 9:15 | Coverage terminated 30 Sep, new plan on file? | Text asking for the new card |
| K. Brooks, 10:30 | HMO referral expired | Request to the PCP's office |
| M. Chen, 1:00 | Deductible remaining $1,850: estimate $320 today | Estimate for the desk |
3Claims checked against the notes before they go out
Most denials are preventable: a missing modifier, a diagnosis that doesn't support the procedure, a bundling edit. The trick is catching them before submission.
Tom's agent reviews each claim against the visit documentation and the payer's rules. It suggests codes for the certified coder to confirm, and flags anything likely to be denied.
| Claim | Flag | Suggestion |
|---|---|---|
| E/M + injection, same day | Modifier 25 missing | Add 25: separate evaluation documented |
| Physical therapy, 4 units | Note supports 3 units (38 minutes) | Bill 3 units |
| Knee arthroscopy | Diagnosis doesn't support medical necessity | Coder to review: meniscal tear documented in op note |
4Denials sorted by what's worth fighting, and appeals written with the records
We get 300 denials a month. Some are typos you resubmit in a minute; some need an appeal letter and the right records; some aren't worth the time. Sorting them was a full-time job.
The agent reads each remittance and denial, groups denials by reason and payer, fixes and resubmits the simple ones for approval, and drafts appeals for the rest with the clinical records attached and the payer's own policy quoted.
| Reason | Count | Amount | Action |
|---|---|---|---|
| Eligibility / coverage | 61 | $22,400 | Corrected and resubmitted (approved by Tom) |
| Authorization missing | 18 | $71,200 | Retro-auth requests + appeals drafted |
| Medical necessity | 23 | $64,800 | Appeals drafted with notes and imaging |
| Timely filing | 9 | $3,100 | Not recoverable: process fix suggested |
5Patient balances explained clearly, with payment plans offered before collections
Patients don't ignore bills because they won't pay. They ignore them because they don't understand them.
After insurance pays, the agent writes each patient a plain-language explanation of what insurance covered and what they owe, offers a payment plan within the practice's policy, and answers follow-up questions by text or email, escalating disputes to staff.
| Outcome | Patients |
|---|---|
| Paid in full | 188 |
| Set up a payment plan | 64 |
| Asked a question (answered) | 41 |
| Disputed, sent to Maria | 6 |
6Incoming referrals and records requests handled the same day
Faxes, portal messages and emails from other offices all land in one queue, and each one needs someone to read it and decide what to do.
The agent reads each incoming referral, matches it to an existing patient or creates the intake, checks the referral covers the right visit count and dates, and offers the patient appointment times. For records requests it checks the authorization, prepares the records and queues them for staff release.
Where people stay in charge
Clinical decisions belong to clinicians, and submissions to payers belong to your staff. The agent assembles, checks and drafts; people approve.
- Nothing is submitted to a payer or released to a third party without staff approval.
- Access to patient information follows each person's role, and every action is logged.
- Each practice's data is separate. It is never used to train shared models.
How to start
- Start with eligibility or denial sorting: clear rules and quick, measurable wins.
- Connect the practice management system, the clearinghouse and the payer portals.
- Run in shadow mode for two weeks and compare with your team's work.
- Move to review mode, then add prior authorization.
Frequently asked questions
Can an AI agent do prior authorizations?
It can prepare them: check whether authorization is required, map the chart to the payer's criteria, assemble the form and records, and track the status. Your coordinator approves each submission, and gaps in the criteria are flagged before submission.
Can AI help with medical billing and coding?
Yes. It reviews claims against the documentation and payer rules, suggests codes and modifiers, and flags likely denials before submission. Certified coders confirm every change.
How does it handle denials?
It reads remittances, groups denials by reason, prepares corrected claims for approval and drafts appeals with the supporting records and the payer's policy.
Is it suitable for dental offices?
Yes. The same workflows apply: eligibility and benefits checks, treatment plan estimates, claims with attachments, and patient balances.
What about patient privacy?
Agents run only where the practice's privacy and security safeguards are in place, with access limited by role and every action logged.
In a 30-minute call we'll walk through your denial report or prior-auth workflow.
The people, companies and numbers in this article are illustrative.