Claims Auditor
Audits every medical claim before payment
Limit
Compliant claims go through with no human touch; denials go to the auditor with the reason.
UpFlux + MV
AI on top of the events in MV.
AI agents and process mining reading what MV already records: each department's charges, the claim closing, the TISS batch and the denial returned by the payer. Claims are reviewed before billing, the auditor decides by exception and patient data does not leave the hospital.
Soul MV, event reading without changing the medical recordA Major Contender in the Everest Group PEAK Matrix® 2026
See also: UpFlux + Tasy · Medical Claims Audit
// digital teamrunning
Soul MV · Care and claims
- Visit 51402 · yellow triageJourney Monitor
- Stroke case 1187door-to-needle in 72 minutes
- Bed 208 · discharged at 9 a.m.waiting for discharge medication
- Claim 90233 · emergency visitwaiting for audit
Clinical decisions stay with the care team; the digital team alerts, chases and audits.
// digital team
Who works in your MV
Each agent has a role, a limit and an audit trail. Anything past the limit goes back to a person, with the case ready.
Journey Monitor
Alerts before the emergency room SLA is breached
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Alerts the team; clinical decisions belong to whoever treats the patient.
Discharge Coordinator
Escalates what holds up discharge and frees the bed
Limit
Chases and escalates; never changes prescriptions or discharge.
Stroke Protocol Watch
Measures every minute of stroke care
Limit
Flags; clinical decisions belong to the care team.
Process Analyst
Answers questions about the process with system data
Limit
Queries and explains; never changes system data.
// what runs on top of your MV
Claims, denials and beds, measured and operated with AI.
Review of 100% of claims before submission
Between discharge and closing, the agent reads every claim, cross-checks each charged item against the prescription, the authorization and the contract price table, and flags what has a likely denial reason, with the suggested correction. The auditor decides.
Denials by payer, with the reason for each one
Every remittance statement returned becomes an event of the claim: the item, the amount and the reason coded in TISS. The hospital sees what each payer denies, and the agent starts checking first what that payer usually denies.
Beds and emergency care
The same events show where discharge waits, which bed turns over least and at which emergency care step the patient waits or walks out. The manager sees it by unit and acts the same day.
RoAI measuring the return in hard currency
Denials avoided, claims closed on time and appeals no longer needed turn into hard currency in RoAI, auditable item by item. Leadership sees what AI returned on top of MV.
// rollout
Diagnostic in 2 weeks, without customizing MV.
UpFlux does not ask for MV customization. You export the claims, batch and denial events from a closed period, and the first map of the real process arrives ready, with the target in hard currency for what is addressable.
01
Event reading
Extraction of the claim, batch, denial and care events from MV, with patient data in the hospital environment.
02
Diagnostic in 2 weeks
From the event export, we deliver the map of the real process and the target in hard currency: variants, bottlenecks and addressable return.
03
Agents in production
The review agent joins the claims queue before closing, with the auditor deciding by exception and every denial avoided measured in RoAI.
// frequently asked
Frequently asked
Questions from hospitals and payers that run MV and are evaluating AI for claims, denials and beds.
Is there AI for claims audit in MV?
Yes. UpFlux reads the claim events in MV (charges by department, closing, TISS batch and returned denials) and an agent reviews 100% of claims before submission, flagging the item with a likely denial reason and the suggested correction. The auditor decides; denials stop being discovered only at the appeal stage.
How do you reduce hospital claim denials in MV?
By reviewing the claim before it goes out, not after the remittance statement. Denials start inside the hospital: an item without a prescription, a price table mismatch, a missing authorization, a deadline or coding. With the MV events, UpFlux flags those items in every claim before closing and learns, with every denial received, what each payer usually denies.
Does UpFlux change MV or the medical record?
No. UpFlux only reads the events that MV already records and hands the prepared decision to the auditor and the billing team. Patient data stays in the hospital environment, under LGPD and with an audit trail per action.
How long does it take to see results with UpFlux on top of MV?
The diagnostic takes two weeks from the event export and delivers the map of the real process with the target in hard currency. The review agent comes in right after, in the claims queue before closing, and every denial avoided is measured in RoAI.
Does UpFlux work for a hospital group with both Tasy and MV?
Yes. The method is the same in both systems: reading the events that already exist, reviewing 100% of claims before closing and the auditor deciding by exception. A group with hospitals on both systems reads claims and denials with the same criteria.
Want to see UpFlux running on top of your MV?
In two weeks, we deliver the map of the real process and the target in hard currency, straight from the claims, batch and denial events.
Talk to UpFlux