Denial Rescue: RossMD

Wrongful Insurance Denials cost USA $30B+, affect millions of lives. 80% of contested refusals get overturned. They rely on difficulty of appeal filling to make a profit. We will change that.

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Inspiration: 30 Billion dollar annual overhead, millions affected

  • 4.1M Medicare Advantage prior-auth denials in 2024
  • Only 11.5% were appealed
  • 80.7% of appealed denials were overturned

The problem is not that appeals do not work. The problem is that vulnerable patients and overloaded hospitals rarely have the time, evidence, or legal context to fight back.

## What it does

Denial Rescue: RossMD is a multi-agent team for hospital admins, appeals nurses, compliance teams, and counsel.

It turns a medical insurance refusal into a reviewable appeal packet with:

  • cited payer policy and CMS rules
  • missing-document checklist
  • clinical evidence map
  • legal/compliance issue spotting
  • peer-to-peer script
  • escalation path for human review

## How we built it

  • Nimble: live web search for payer policies, CMS rules, and current authority
  • ClickHouse: legal memory layer with corpus search, vectors, traces, and knowledge graph
  • Datadog: multi-agent observability, A/B testing, latency, and quality improvement
  • OpenRouter/Gemini: agent reasoning, drafting, adversary review, and QA
  • FastAPI + Next.js: live Agent Theater demo with streaming agent activity

## Challenges we ran into

  • Converting denial letters, payer policies, CMS rules, and chart facts into one trustworthy workflow
  • Preventing hallucinated legal claims by forcing citation-backed outputs
  • Encoding laws, company policies, prior cases, and appeal logic into a dense knowledge graph
  • Designing autonomy while keeping humans in control for legal and clinical judgment

## Accomplishments that we're proud of

  • Built a live multi-agent appeal pipeline end to end
  • Retrieved real sources and cited every important claim
  • Added missing-evidence detection before drafting
  • Produced a reviewable appeal packet, not just a chatbot answer
  • Created replayable traces so every run can be audited and improved

## What we learned

The bottleneck is not legal intelligence alone.

The real bottleneck is coordination across:

  • payer policy
  • medical evidence
  • appeal deadlines
  • CMS rules
  • legal citations
  • human approval

RossMD wins by coordinating the work before time runs out.

## What's next for Denial Rescue: RossMD

  • Pilot with hospital appeals and care-management teams
  • Add payer-specific playbooks for UnitedHealthcare, Humana, Aetna, Cigna, and BCBS
  • Learn from appeal outcomes over time
  • Measure reversal rate, packet completion time, evidence completeness, and avoided unsafe discharges
  • Expand from Medicare Advantage denials into ERISA, ACA external review, No Surprises Act, and fraud/compliance workflows

## Built With

OpenRouter/Gemini · ClickHouse · Nimble · Datadog · FastAPI · Next.js · local embeddings · healthcare regulatory corpus

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