Decision panels

The decision core is rules and people. The four panels are the four places where disputed items go to a human for authorization, and the product makes that decision fast, specific and defensible.

Act panel: disputed act lines

Who works here: the billing office; the department head — for lines with clinical content.

A queue of disputed lines on the way from bound terms to the act: a service without a reliable binding to the document, an ambiguous tariff, a mismatch between the note and the billed service. No such line enters the act silently — fail-safe by principle.

• An act that will not bounce: disputes surfaced and resolved before submission.
• Work in the cheap “before the claim” phase instead of the expensive “after the denial” one.
• Clinical and financial pictures consistent by construction.

Metric: share of acts submitted without a subsequent denial.

Boundary: signing the act is a human action outside the product; the panel prepares the decision for the signer, not the signature.

Dispute panel: working a denial

Who works here: billing-office dispute specialists; legal — for escalations.

The clinic’s internal workplace for received denials: for every denied line — the payer’s reason, the full transformation chain, the history of decisions made on the binding and act panels, and the pipeline’s recommendation: contest with evidence, correct, or write off. The decision is human.

• A denial position in minutes instead of hours: the line history is already assembled.
• A ready evidence pack for escalation — no manual assembly.
• Faster recovery of the denials that do get paid in the end.

Metric: cost of working one denial; share of denials contested successfully on the first response.

Reconciliation panel: joint resolution with the insurer

Who works here: the insurer’s expert and the clinic’s representative.

A joint workplace for the two sides of a dispute: both see the same transformation chain for every contested line — the source fragment in the minimum necessary scope, the bound term, the descriptor with its version and author, the code, the tariff. The subject of reconciliation is evidence of care delivered, not opinions.

• Disputes resolved by presentation, not by correspondence.
• Per-line decisions are recorded — the dispute does not reopen.
• A non-repudiable reconciliation record protects both sides.

Metric: dispute duration from denial to closure; share of lines closed without escalation.

Boundary: the panel does not decide who is right — it makes the evidence shared; decisions and signatures remain with the parties.

Binding panel: disputed term recognition

Who works here: clinical coders; the physician — for clinically significant bindings.

A queue of bindings where automation has no right to decide: semantic-search candidates, equally strong variants, terms missing from the vocabulary. The operator sees the source fragment, the ranked candidates and their definitions — and authorizes the choice. Missing terms become vocabulary-extension candidates.

• A choice between grounded candidates instead of reading the whole document.
• Higher throughput without higher risk: every decision is recorded and grounded.
• Every confirmation improves future coverage — the automatic-binding share grows.

Metric: share of documents needing no manual decisions; median decision time per line.

Boundary: queue growth beyond operator capacity is a signal to improve vocabulary coverage, not to rush the operators; the panel shows this metric explicitly.

The panels are linked: the better binding conflicts are resolved, the fewer disputed lines reach the act; the cleaner the act, the fewer disputes reach the insurer. The product is honestly built to unload itself over time — value shifts from resolving conflicts to preventing them.