InRule® for Healthcare
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.
Read more.
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.
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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.
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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
Read the Case Study
InRule Technology is a Corporate Sponsor of the Microsoft Health
Users Group.
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More information for Plans and Payers
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More information for Providers
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Additional Resources
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
Recorded Demonstration:
"Healthcare Rules! Using Rule Technology in Healthcare Systems"
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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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