Underpayment-Recovery & Payer-Contract-Compliance AI Agent
Model what the contract said a paid claim should pay, read the remittance for what actually happened, explain each variance against the contract term behind it, and assemble the dispute a contract manager releases.
A remittance posts against a claim already paid, from supported clearinghouse, payer portal or 835 sources.
02
The CARC and RARC codes are normalised, and each line carries forward the remittance it came from.
Reason
03
The contract and fee schedule are modelled for what the claim should have paid, carve-outs included.
04
The remittance is read for what happened — adjustments, take-backs and recoupments — against that rate.
05
Plan-funding status is established first: fully-insured, or self-funded and ERISA-governed.
Decide
06
A payer overpayment is flagged with the same discipline as an underpayment, and a silent denial too.
07
Every modelled variance, with the contract term behind it, routes to the named contract manager for release.
Out
08
The contract term, the remittance evidence, the manager's edits and the release stay on the claim.
09
Execute write actions only inside the approval boundaries agreed during implementation.
→Product statement
The agent models the variance and assembles the dispute; the contract manager decides whether it is released, and provider standing and plan type are confirmed before anything moves.
Example workflow
One claim, remittance to release
AgentHuman
1Remittance received835 remittance, clearinghouse feed, payer portal or lockbox scan
2Context assembledContract term, fee schedule, plan-funding status and remittance history, each with its source
3Variance modelledModelled rate, actual payment, contract term cited and confidence
4Controls appliedLookback-window checks, plan-type checks, standing checks and confidence threshold
No human action required
Stages 1 to 4 run unaided, and no dispute is assembled at any of them — the agent is modelling, and the manager's lane opens at the confidence gate.
5DecisionBranches at the confidence threshold
High confidence
Goes to the contract manager to release.
Low confidence
Adds a compliance read first.
Manager release
The claim is held with its modelled variance, its contract citation and the confidence.
Release · Edit · Send to compliance review
Released — dispute assembled▼
6Contract-manager system updatedOnly where write access and approval policy allow it
7Outcome evaluatedVariance accuracy, manager edits, dispute outcomes and overpayment-reporting completeness
Manager edits
Every manager edit made at release is counted in the evaluation.
What should not run autonomously
Human approval stays in control
Outside the boundary — human approval required8 items
Filing a dispute, appeal or demand with a payer.
Adjusting, writing off or accepting a claim balance.
Deciding that a payer's adjustment was improper.
Filing the federal 60-day overpayment report or return.
Automation boundaryAgent acts unaided
✓Model the contract rate and read the remittance for what actually paid.
✓Carry every contract citation forward with the remittance line it explains.
✓Apply the state's configured lookback window and notice.
✓Flag a payer overpayment or a silent denial, and hold.
Any write happens inside the boundaries agreed at implementation, never ahead of the manager's release.
Confirming provider standing where an anti-assignment clause is at issue.
Applying one lookback window across states that set 180 days, 24 months and 365 days.
Determining ERISA/self-funded status where the plan record is unclear.
Changes to lookback rules, plan-type logic or release thresholds.
Example output
One claim, annotated
Everything the agent models is attached to the claim it was drawn from.
Variance output · single claimIllustrative example
Claim
Modelled variance
Payer & plan type
Contract clause
Confidence
Manager status
Post-payment take-back, in-network
Recoupment applied against the negotiated bundling rate — the contract's implant carve-out was not credited
Texas · state lookback rule
Signed contract on file
91%
Plan confirmed fully-insured
As receivedTaken from the claim record and the signed contract on file — nothing on this side is decided by the agent.
Evidence assembledContract clause and rate835 remittance codesState lookback rule
Why this reads as a varianceThe remittance doesn't match the contract's carve-out term and a person still decides.
ActionReleaseEditSend to compliance review
What the score decidesBelow the configured threshold the claim picks up a compliance read before.
Value
Where AI adds value
The same four claims, placed at the point in the workflow where each one applies.
Where the value landsValue 01 – 04
Every remittance postedFrom the remittance feed
03Variance modelling
Model against the contract
Weigh the actual payment against the contract term, the fee schedule and the state's configured rules.
01Approved path
The duty runs both ways
A payer overpayment is surfaced with the same rigor as an underpayment — the model doesn't only look one direction.
02Human review
Point the manager at what needs
Silent denials and low-confidence variances are marked, so the manager's read starts where the contract is ambiguous.
04Build an evidence trail
The variance, the contract term it was read against and the manager who released it stay on the claim.
Integrations
Typical integrations
Five system groups connect to the same agent. Which of them are in scope is decided in discovery.
One payer contract can hide inside a portfolio number
A portfolio recovery rate can look strong while a handful of claim categories absorb nearly all the rework. Nestack reports the variance-rework rate by claim category, not only in total.
Slice performance — reported separately, not only in aggregateIllustrative example
Slice
Failure rate
Lift
Lift vs. threshold
Status
Post-payment take-backs on paid claims
7.8%
4.0×
Review
Carve-outs, implants and stop-loss terms
5.4%
2.8×
Review
Bundled and multi-procedure reductions
3.5%
1.8×
Watch
Single-line fee-schedule claims
1.9%
0.7×
Normal
Bar: variance-rework rate lift vs. the single-line fee-schedule baseline · scale 0–4.0× · tick at 2.0×2 of 4 slices over threshold
Evidence-linked improvement
The loop does not close at recovery
A cycle shuts when the missed overpayment is a case the next release has to catch. That suite is what the next remittance read is measured against.
Improvement cycle · five stagesSwitchback — the path turns at Improve and returns at Learn
01Detect
Variance-rework rate rises in a claim-category slice.
02Diagnose
The take-back that arrived as an adjustment is traced to the remittance code, the contract term or the fee-schedule load behind it.
03Improve
The change ships against a version, with the claims that exposed it attached.
04Verify
A failing variance case holds the release until it clears.
05Learn
The case joins the standing suite and the contract rules move with it.
Learn → DetectThe return edge. The next remittance read runs against a suite one case longer.
Typical build scope
Twelve workstreams across six weeks
The build scope read against the delivery timeline. Week structure follows the six-week plan — discovery, sources, variance workflow, evaluation, integration, then production validation and handover.
WorkstreamWeek 1Week 2Week 3Week 4Week 5Week 6
01Recovery-workflow discovery and boundary definition.
02Contract and remittance-source review.
03Lookback and plan-type-config mapping and rule mapping.
04Claim ingestion and normalisation.
05Variance modelling and contract binding.
06Confidence scoring and flag routing.
07Manager release workflow.
08Contract and billing-system integration.
09Variance and lookback cases.
10Guardrails and release controls.
11Claim-trail instrumentation.
12Deployment, documentation and Agent Care handover.
12 workstreams · 6 weeks · bar shows the weeks a workstream is active — several run in parallelFinal scope and sequence confirmed in discovery
Engagement tiers
What each tier includes
Rows are the capabilities named in each tier's scope. Higher tiers include everything below them.
Capability✓ in scope · — not at this tierPilotOne payer, one contractProductionProduction billing-system integrationAdvancedMultiple payers / entities
Introduced at Pilot
Variance modelling and contract recommendations✓✓✓
Manager release✓✓✓
Variance-accuracy baseline✓✓✓
Introduced at Production
Reporting by payer—✓✓
Release workflow in your systems—✓✓
Approved dispute-packet write-back—✓✓
Remittance integration—✓✓
Introduced at Advanced
Multi-payer and multi-state rules——✓
Multi-stage manager approvals——✓
High claim volume——✓
Multi-contract recovery controls——✓
Build priceFrom $5,000From $8,000Custom quote
Final build priceConfirmed after discovery based on integrations, workflow complexity, transaction volume, approval controls and deployment requirements.
Separate from buildBuild pricing is separate from recurring Agent Care, which covers managed monitoring, evaluations, incidents and verified improvements after launch.
What we need from you
What you bring, and what we build with it
Each input maps to a piece of build scope and a week in the delivery timeline.
You bringWe build with it
01Your payer contracts, fee schedules and remittance access→Contract ingestion and fee-schedule mappingWeek 1
02Representative claims across payer and category cohorts→Variance-modelling baseline and remittance bindingWeek 2
03Your state lookback rules and plan-type determinations→Lookback-rule and plan-type-config mappingWeek 1
04Access to relevant APIs, feeds or exports→Contract, remittance and billing-source assessment, then integration setupWeek 2
05Disputes you would not want filed→Overpayment cases and the evaluation suiteWeek 4
06What no variance may assume→Confidence scoring, flag routing, guardrails and release controlsWeek 3
07Named contract managers to release disputes→Manager release workflow, then pilot and production validationWeeks 5–6
Nothing else is requiredDeployment, documentation and Agent Care handover are ours.
Delivery timeline
Four phases across six weeks
Each band sits on the weeks the work occupies, so week 5 runs evaluation and pilot together.
PhaseW1W2W3W4W5W6
DiscoveryW1
BuildW2 – W3
EvaluateW4 – W5
Pilot & LaunchW5 – W6
Week focusW1Recovery-workflow discovery, lookback mapping and the boundaryW2Contract and remittance integration, and the variance baselineW3Variance modelling, confidence logic and release controlsW4Evaluation suite, guardrails and failure-mode testingW5Billing-system integration, pilot claims and targeted correctionsW6One remittance cycle worked under the contract manager, then Agent Care handover
Reading the bandA bar covers the weeks its work is named in, and nothing else. The week 5 overlap is real, not padding.
At the end of W6The final checks clear on live claims and monitoring moves to Agent Care.
DurationSix-week plan shown · typical delivery 4–6 weeks depending on scope confirmed in discovery.
Next step · Healthcare AI agent
Build an underpayment-recovery agent for claims that already paid — not pre-payment appeals, not aged AR.
Show us your contracts, your remittance feed and who releases a dispute. Next, we'll map the contract terms against your remittance data, set the state-by-state lookback rules, and name what only your contract manager releases.
