• InRule® for Healthcare

    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 Exchange
    With 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 Systems
    InRule 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 Eligibility
    Automating 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:

    • Data validation: electronic intake forms can be complex and often have contingent validation requirements, for example requiring a field only if numerous other fields are populated a certain way.
    • Configurable user interface: Rules are be used to drive the user interface so that only certain questions are asked on an application, sometimes based on previous answers. Rules are also used when the interface displays such things as processing status, error codes/exceptions and a final disposition.
    • Complex calculations: Eligibility applications typically have a large number of calculated fields, including values such as income, assets and deductions. InRule’s ability to calculate filtered attributes and roll those up to a parent entity is helpful determining, for example, how much of an applicant’s income and assets apply toward eligibility for a certain program.
    • Application classification: rules are used to help accurately classify an application as eligible or not eligible for certain programs, based on numerous calculations and federal policy and state regulations.
    • Routing: Rules determine whether and how an application should be routed for further review or what, if any, further verifications are needed.

    Social Services and Healthcare Eligibility
    The 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. 
     

    Ensuring Consistent Decision-Making and Decisive Results throughout the Healthcare Revenue and Care Cycles

    Decision Logic and Business Rules

    Decision logic is the underlying code that is used to automate business processes. For example:

    • Underwriting decision logic includes risk assessment rules and other calculations
    • Health plan decision logic includes the rules that determine coverage and co-pays
    • Population management decision logic includes the rules that define a population as well as the resulting actions

    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. 

    • Author custom rules and update them easily, without custom programming
    • Easily integrate and interoperate with existing and new applications
    • Manage rules across applications with flexible, powerful rule management

    InRule Powers Healthcare Solutions

    For Plans and Payers

    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.

    More information for Plans and Payers 

    For Providers

    InRule helps manage and automate the rules that govern the complex and changing relationships between data, such as test results, population characteristics, and protocols.

    More information for Providers 

    Case Study

    “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  

    Read the Case Study 

    Additional Resources

    MS HUG
    InRule Technology is a Corporate Sponsor of the Microsoft Health Users Group.  

    Request a White Paper: Improving Decision-Making Interoperability and Consistency for Health Insurance Plans with Business Rule Technology

    Technical Product Information: Read more online about how InRule works

    Download Free Trial

    Recorded Demonstration: "Healthcare Rules! Using Rule Technology in Healthcare Systems"

    Watch the Video    

    HMO Product Customization

    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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    MDS 2.0

    "The implementation delay stems from concerns that the original start date did not provide enough time for software vendors, state agencies, and other systems to properly prepare for the MDS 3.0."

    Rena R. Shephard
    Founding Chair & Executive Editor, American Association of Nurse Assessment Coordinators
    President 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.

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    Claims Processing

    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:

    • Helps automate creation of payer files from claim files, streamlining the claims process
    • Enables easy updates to reimbursement rules without custom programming
    • Delivers first-time pass yield for claims of 98% (significantly better than the industry average of 90-92%)
    • Provides better performance than the hard code it replaced!

    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.

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