InRule for Healthcare for Plans and Payers
Optimizing Revenue and Streamlining Compliance by Automating and Managing Healthcare
Rules
The traditional methods of ensuring compliance to healthcare rules and regulations—such
as CMS Medical Necessity and Private Plan payer rules—are complex, time-consuming,
highly subject to error, and expensive. InRule® externalizes and automates decision
logic for plan and payer applications (e.g., coverage determination and reimbursement,
making it consistent among systems, easy to update by both developers and subject
matter experts, and more transparent and auditable.
Optimizing the Healthcare Revenue Cycle
InRule
provides a foundation for the consistent management of reimbursement rules throughout
the reimbursement cycle, delivering cleaner claims and faster payments
for Providers, Payers, and the Claims Clearing houses that serve them.
- Providers
- Simplified compliance with CMS and commercial
payer policies
- Reduced frequency of denials
- Optimized reimbursement
- Payers
- Elimination of cost of claims rework
- Inbound claim scrubbing
- Eligibility checking and prior authorization
- Pricing transparency
- Claims Clearing Houses
- Improved, rule-enabled claim scrubbing
- Competitive advantage due to enhanced service
Cleaner Claims and Faster Payments
InRule-enabled systems can help reduce denials, which cause nearly 50% of lost hospital
revenue. One of the top claims management services in the United States is deploying
an InRule-powered claims processing system to help automate creation of payer files
from claim files. Their InRule-powered solution provides the foundation for reimbursement
rules to be managed consistently through the reimbursement cycle, delivering these
benefits:
- Enables easy updates to reimbursement rules without custom programming
- Delivers first-time pass yield for claims of 98%
By managing reimbursement rules consistently through the reimbursement cycle, InRule
helps deliver cleaner claims and faster payments for physicians, payers, and clearinghouses.
