Use casesServices

Hospital claim pre-audit for SGK

Before each month's invoice to SGK, every billed line has to be written in the epicrisis and fit the SUT's rules, or the review cuts it months later.

With the systemEach episode's billed lines matched to the record and checked against the SUT; the billing officer corrects and closes.

Who decides
Billing and medical coding officer

HBYS · surgery note · 22 October 2026

Surgery note · laparoscopic inguinal hernia repair, right

Under general anesthesia the preperitoneal space was entered laparoscopically and the hernia sac reduced; a polypropylene mesh was placed over the defect. Hemostasis checked; trocar sites closed.

→ no fixation device written · billed line 3 unsupported

Illustrative The document as it arrives. In red, what the system marks for your expert.

1. The work

Today

  1. GatherBefore each month's invoice to the Social Security Institution (SGK), the billing team opens every inpatient and surgical episode in the hospital information system (HBYS): the billed lines with their SUT codes, the materials with their barcodes, the drugs, the epicrisis, the surgery notes, and the reports.
  2. ReadMedical coders read the epicrisis and the surgery notes line by line to see that each billed procedure and material is written there, and to catch procedures done but never billed.
  3. CheckThey check the Health Implementation Communiqué (SUT) by hand: what a diagnosis-based package already includes, how several procedures in one session are billed, whether each material is registered in the product tracking system (ÜTS) with its barcode, and whether a required report is on file.
  4. DecideThe billing officer corrects the lines, asks the physician to complete any missing documentation, and submits the month's invoice in MEDULA; whatever SGK's review later finds unsupported is cut (kesinti) from the payment.

With the system

  1. GatherThe agent plans one worker per billed line of each episode and gathers, read-only, the record that line needs: the epicrisis, the surgery note, the report, the material's ÜTS record, all cited.Agentic AI
  2. ReadThe SLM reads the epicrisis, the surgery notes, and the reports and quotes, for each billed line, the sentence that supports it; it marks lines the record does not support and procedures written but not billed.SLM
  3. CheckYour written rules, taken from the current SUT and its annex lists and run as code, check packages, same-session billing, ÜTS registration and barcodes, required reports, and the invoice period.Your rule
  4. DecideThe billing and medical coding officer reads the file and corrects the invoice, as before; only the physician completes the medical record, and only the hospital's own staff submit the month's invoice in MEDULA.Person decides

What lands on the desk

The billing officer gets each episode with every billed line matched to the sentence that supports it, the SUT rules checked by your own code, and the gaps named before the month closes. The file never changes a line or the record; the corrections and the invoice stay with the hospital's team.

FIG. 1 · Pre-audit fileIllustrative
Inpatient episode · general surgery · October 2026 invoiceLaparoscopic inguinal hernia repair with mesh

Agent · episode gathered

  1. 1Five billed lines read: the package procedure, a mesh, a fixation device, a blood count, an ultrasoundHBYS
  2. 2Epicrisis and surgery note openedHBYS
  3. 3ÜTS records looked up for both materialsÜTS

SLM · billed lines against the record

  • metHernia repair: laparoscopic, right side, written in the surgery notesurgery note
  • metMesh placement written in the surgery notesurgery note
  • flaggedFixation device billed, not written in the surgery notesurgery note

Code · SUT rules

  • flaggedBlood count and ultrasound during the stay billed apart from the packageSUT 2.2.2.B-1
  • metMesh registered in ÜTS, barcode on fileSUT 3.1.1
  • flaggedFixation device barcode not on fileSUT 3.1.1
  • metEpicrisis written in detailSUT 5.3.1.C

SLM · for the billing officer

Three points before the invoice: two tests the package already covers, and a fixation device the surgery note does not mention and whose barcode is missing. Question for the surgeon: was the device used? Only the surgeon can add it to the record.

  • SLM
  • Agent
  • Code

Why a person decidesThe billing officer corrects the invoice; only the physician completes the record. The system never edits the record or sends anything to MEDULA.

DecidesBilling and medical coding officer

2. The system

For your technical team — skip it if you like.

How it works

In

  • The month's episodes and billed lines
  • Epicrisis, surgery notes, and reports
  • Materials, barcodes, and ÜTS records

  1. Agent · acts

    Episode file agent

    Coordinator and one worker per billed line; read-only

    Reads

    • Everything under In

    Out

    • Each billed line with its record
    • Missing documents listed
    • One file per episode

  2. SLM · reasons

    Clinical record reader

    SLM, with retrieval over the current SUT and its annex lists

    Reads

    • The episode file
    • The SUT and its annex lists

    Out

    • The sentence behind each billed line
    • Lines the record does not support
    • Procedures written but not billed

  3. Code · calculates

    SUT rule checks

    Your written rules from the SUT, run as code; no model

    Reads

    • Billed lines and SUT codes
    • Package windows and session rules
    • ÜTS records and reports on file

    Out

    • Items inside a package billed apart
    • Same-session billing
    • Material registration and barcode
    • Required reports present

  4. Decision

    Billing and medical coding officer

    Reads

    • The file and its citations

    Out

    • Corrects the billed lines
    • Asks the physician to complete the record
    • Submits the month's invoice in MEDULA
How the agent's work is arrangedOrchestrator–workers

Orchestrator–workers

Each episode brings its own billed lines and documents, so a coordinator plans one worker per line present and assembles what each finds into one file.

How the models are trained and tested

Your expert writes the test first. A step the test does not need is skipped, and we say why.

Show the training steps

Small language model (SLM)

  1. Test set

    200–400 past episodes with your coders' corrections and the reasons SGK gave for its cuts, graded by your senior medical coders, each billed line labeled with the sentence that supports it or its absence.

  2. Dataset

    Past episodes, coder corrections, and SGK cut and objection letters; names and identity numbers masked in training copies; records never leave your servers.

  3. Continued pre-training (CPT)If needed

    Only if the base model fails the test on Turkish clinical language and surgical abbreviations.

  4. Supervised fine-tuning (SFT)

    On matching record sentences to billed lines in your hospital's epicrisis and surgery-note formats.

  5. Reinforcement learning (RL)Skipped

    Skipped: matching and quoting are taught by fine-tuning, and no further reward is needed.

  6. Retrieval

    Retrieval supplies the SUT and its annex lists as amended today and SGK's announcements; the SUT changes often, so the rules are reloaded after each amendment, never kept in the model.

  7. Monitoring

    The billing officer reviews every file; each SGK cut the file missed joins the next test.

Where the agentic system stops

The billing and medical coding officer decides every correction and submits the month's invoice; the physician alone completes or corrects the medical record.

Show its tools, limits, and record
Tools and access
Reads the hospital information system's episodes, billed lines, epicrises, surgery notes, and reports, and the material records and ÜTS lookups, only for the month being billed; read-only; writes only the pre-audit file.
May not
Edit the medical record, add or change a billed line, close the invoice period, send anything to MEDULA or SGK, contact the patient, read episodes outside the month being billed, or grant itself any access.
Who decides and the written limit
Billing and medical coding officerThe billing and medical coding officer decides every correction and submits the month's invoice; the physician alone completes or corrects the medical record. The system never edits the record, never changes a billed line, and never sends anything to MEDULA or SGK.
Stops when
A record it cannot read with confidence, a billed line no written rule maps to, an SUT change newer than the rules loaded, or a traffic accident, work accident, or forensic case: the episode goes to the billing officer, marked.
Record
Every episode, line, and document read, each check and the SUT provision and rule version behind it, the file, and who corrected the invoice and when.

How agentic systems stay inside limits

3. Value and conditions

Where the time goes, and what your institution will measure.

Where the value comes from

  1. Fewer SGK cuts for missing documentation.
  2. Documentation gaps found while the physician can still complete the record.
  3. Procedures done but not billed found before the month's invoice goes out.

What your institution measures

  • SGK cuts per invoice period
  • Lines corrected before the invoice
  • Coder time per episode
  • Objections to cuts the hospital wins
  • Episodes billed in their own period

Measured in the Decision Blueprint

Today's SGK cuts per period and coder time per episode, from your billing records, set the baseline; your institution sets the target.

Conditions

The rules, the data, and the known error, with its guard.

  • A provision taken from MEDULA is only a prior permission and is not enough on its own; checks for rules not built into MEDULA are the hospital's (SUT 5.1(4)). Records, documents, and reports not shown on request mean the billed amounts are not paid (SUT 2.2(12)).
  • An inpatient procedure on the diagnosis-based list (EK-2/C) is billed as a package (SUT 2.2.2(1)) that already includes the bed, examinations, the operation, anesthesia, drugs during the stay, consumables, and laboratory, pathology, and radiology tests, within the window its group sets, from 15 days for group A down to 3 for group E (SUT 2.2.2.B-1).
  • A material is paid only when registered in TİTUBB/ÜTS, and its barcode is kept in the patient's file (SUT 3.1.1(2)–(3)); the service detail record carries the ICD-10 diagnosis, each procedure's SUT code, and each material's barcode, and the epicrisis is written in detail for every inpatient and surgical episode (SUT 5.3.1.C).
  • Health data is special-category personal data (KVKK art. 6): the system runs on the hospital's servers, reads only the month being billed, and one hospital's records never train another hospital's model.

Start here

We take one month's inpatient and surgical episodes with your billing team, time the pre-audit, collect SGK's cut letters for the last periods, and test the reader on your own epicrises and surgery notes before anything is built.

Who builds it Every engagement is led by an engineer who has built machine-learning models that real decisions run on since 2012, and language models and agentic systems in production since 2024. About eqlx

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https://eqlx.ai/use-cases/medula-claim-audit · Printed copy; the website is the current version.