• 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

    Healthcare Revenue LifecycleInRule 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.