Healthcare and health plans
Back-office operations with a high volume of documents and explicit rules on the autonomy of AI agents — CFM Resolution 2.454/2026 treats the degree of autonomy as a risk-classification factor.
Declared scope limit
Scope deliberately restricted to the back office: billing, claim denials, authorization, and medical bill auditing. AI agents never make clinical decisions. CFM Resolution 2.454/2026 is explicit, and we follow it strictly.
Agent scope: back office
- Billing
- Claim denials
- Authorizations
- Medical bill auditing
Out of scope: clinical decisions
Diagnosis, prognosis, and treatment are decisions made by people.
Processes fit for AI agents
- Medical bill auditing and claim denials
- Billing and verification
- Procedure authorization
- Health plan document checking
Examples of units of work
- Medical bill audited
- Document checked
- Request processed
Recommended Skill Pack
Medical bill auditing, approvals, and claim denials
Medical bill received
Check against the health plan contract and fee table
Audit the bill and propose a disallowance
- LGPD, art. 20
Disallowance or denial: an identified auditor decides
An identified person decides
Medical bill audited
Billable unit
Evidence
When the other side has an agent
Procedure authorization is already a negotiation between two sides: the provider requests, the health plan authorizes. With agents on both sides, each one needs an owner and a record, and the clinical decision stays out of scope.
Compliance
Compliance standard examples
- Res. CFM 2.454/2026 (Federal Council of Medicine)
- Prohibits delegating the final diagnostic, prognostic, or therapeutic decision to AI systems. Requires clinical record keeping and continuous auditing, and treats the degree of autonomy as a risk-classification factor.
- LGPD, art. 20 (Brazil's data protection law)
- Health data is sensitive data; review of an automated decision is the data subject's right.
Our read
Formal adoption of AI in healthcare remains low, but the opportunities are huge, making the document back office the lowest-risk entry point and the one with the highest immediate return.