The upholding of the Affordable Care Act renews the urgency of the Health Insurance Exchange programs, which all states are required to have operational by January 2014. Business Rule Technology such as InRule will be an essential component of any Health Insurance Exchange seeking to meet this deadline.
Driving Health Insurance Exchange programs are many complex and frequently changing rules that determine a citizen’s eligibility based on many factors such as age, employment status, family status, income, and assets. Rules also drive details of health plans such as which procedures are covered, co-pays, deductibles, and approved medications. By managing these rules outside of code, InRule brings improved quality and increased efficiency—key as states race to meet the January 2014 deadline.
InRule is used by Health and Human Services organizations committed to using technology more effectively in systems that address healthcare mandates and compliance. Through software innovation, they deliver solutions for the health industry that help improve health around the world.
Health Insurance ExchangeWith the Affordable Care Act directing States to establish Health Insurance Exchanges (HIX) by 2014, the race is on. Exchanges will offer a choice of different health plans, certifying plans that participate and providing information to help consumers find the best plan value according to their specific health issues and provider networks. While private Exchanges focus on optimizing plan selection for each consumer, State-regulated Exchanges have the added complexity of determining eligibility and making available federal subsidies for qualified citzens. InRule is perfectly suited to both the Eligibility and Pricing aspects of HIX, enabling geographic- and time-specific rules; managing complex calculations, and allowing subject matter experts to update rules as policies, programs, plans, providers and requirements change.
Medicaid Management Information SystemsInRule has been deployed in Florida, Georgia, Oklahoma and Ohio for Medicaid Management Systems as part of a solution that reduced the timeframe for provider reimbursement by 81%. For public sector and private sector clients, InRule provides a foundation for the consistent management of reimbursement rules throughout the reimbursement cycle, delivering cleaner claims and faster payments for Providers and Payers. With InRule, providers can reduce the frequency of denials, optimizing reimbursement. Health Plans can eliminate the cost of claims rework and streamline eligibility checking and prior authorization.
Medicaid EligibilityAutomating eligibility systems and reducing or eliminating manual processing can enable eligibility determination to be made in minutes rather than weeks or months. Several states are using systems powered by InRule, building in the flexibility to accommodate major changes such as adding new services and document types, changing validation criteria, or re-configuring routing rules. With InRule, these changes can be made without code changes.Rules are used in these systems in several areas, including:
Social Services and Healthcare EligibilityThe agency responsible for directing and overseeing healthcare dollars to hospitals and other cancer care providers within Ontario uses InRule. They are funded by the Canadian Government and are responsible for distribution of over $700 million public healthcare dollars. They administer the New Drug Funding Program (NDFP), which funds new and often very expensive cancer drugs, to ensure that Ontario patients have equal access to high-quality intravenous cancer drugs. As the Government of Ontario’s cancer advisor, their mandate is to reduce the number of people diagnosed with cancer and make sure patients get better care every step of the way.
Their new solution replaces the existing NDFP operational database and provides program, policy, claims, and web content management for NDFP operations. The system automates processes, streamlines adjudication of claims, and improves turnaround times for reimbursement of cancer drug costs to hospitals. InRule drives the rules that determine a patient’s enrolment eligibility in a particular policy as well as reimbursement eligibility for patients’ treatments.
Decision logic is the underlying code that is used to automate business processes. For example:
When decision logic is “hard coded” (written in program code by developers) it is difficult to share, time consuming and expensive to change.
Business Rules are used to separate important decision logic from the rest of the application code, making it easier to update, manage and share across applications.
In most healthcare organizations, business rules and decision logic are siloed across separate systems, potentially resulting in inconsistent decisions made in every area of healthcare – from underwriting to pricing, from benefit verification to reimbursement, from case management to treatment plans.
InRule enables decision logic to be shared and managed across applications and platforms, ensuring consistent decision-making throughout the healthcare revenue and care cycles.
Healthcare applications are built using InRule for Healthcare.
InRule provides the foundation for reimbursement rules to be managed consistently throughout the reimbursement cycle, delivering cleaner claims and faster payments for physicians, payers, and clearinghouses.
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InRule helps manage and automate the rules that govern the complex and changing relationships between data, such as test results, population characteristics, and protocols.
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“Now, we can use the business rules engine to drive specific contract behaviors for every case we process. We can enforce specific rules, and if a problem comes up, the system provides specific information to people about what’s needed to solve the problem.”
Jason Rosenberg, VP of IT and Application Development, Access MediQuip
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Technical Product Information: Read more online about how InRule works
Recorded Demonstration: "Healthcare Rules! Using Rule Technology in Healthcare Systems"
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The U.S.’s largest not-for-profit health plan offers dozens of basic HMO plans in each of the 10 states it services, with custom co-pay rules for organizational clients. Each HMO plan has more than 450 rules that determine co-pay rules, which are defined by treatment and in relation to one another. Clients want to determine co-pay rates for various services and the Health Plan’s representatives want to easily create custom plans for clients, while complying with co-pay rules.
A Rule-Enabled Approach enables the Health Plan’s representatives to quickly and cost effectively offer clients customized co-pay plans that comply with internal rules. InRule provides a way for co-pay rules to be updated as necessary.
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Rena R. ShephardFounding Chair & Executive Editor, American Association of Nurse Assessment CoordinatorsPresident of RRS Healthcare Consulting Services in San Diego, CA.
Minimum Data Set (MDS) is a tool used by skilled nursing facilities to assess residents and determine Medicare payments. Because MDS 2.0 rules were hard-coded in many applications, vendors and agencies could not quickly change their applications to support MDS 3.0. is rigid approach to rule management led to the delay of MDS 3.0 a full year to October 2010. Vendors, state agencies, and facilities planning for the upgrade to MDS 3.0 can benefit from using InRule to externalize the MDS rules that govern the questionnaires providers use to assess patients.
One of the top claims management services in the United States processes 250 million claims annually, with 500 million revenue cycle management transactions overall. An InRule Powered Claims Processing Solution:
InRule can provide the foundation for reimbursement rules to be managed consistently through the reimbursement cycle, delivering cleaner claims and faster payments for physicians, payers, and clearinghouses.