Healthcare Receivables Rules Engine Automation
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Solution Overview
Problem
Current healthcare accounts receivable management systems face inefficiencies due to the complexity introduced by third-party payers, including the need for manual handling of denials, lack of standardization in denial reasons, and inefficient aging processes, leading to labor-intensive collections and inaccurate forecasting of reimbursement.
Innovation Solution
A system and method utilizing a rules engine, transaction engine, remittance processing engine, nightly aging engine, and reimbursement management engine to automate the assessment and processing of encounters, denials, and reimbursement, enabling real-time tracking and categorization of receivables, and facilitating timely and efficient collection by standardizing payer responses and aging processes.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Ease of operation
If manual handling of denials is used, then flexibility in processing individual cases is maintained, but labor intensity and processing time increase significantly
Solution Approach 1:
The system segments denial processing into automated rule-based evaluation and manual review components. Rules engines automatically process standard denials using predefined criteria, while complex cases are routed to human reviewers. This segmentation maintains flexibility for individual case assessment while significantly improving overall processing efficiency through automation of routine tasks.
Solution Approach 2:
The patent introduces an intermediary rules engine that acts as a mediator between manual denial handling and final processing decisions. This intermediary automatically evaluates denials against standardized criteria, providing recommendations that reduce labor intensity while preserving human judgment for exceptional cases, thus balancing flexibility and efficiency.
2Adaptability or versatility
If non-standardized denial reasons are used, then specific payer nuances are captured, but processing complexity and difficulty of analysis increase
Solution Approach 1:
The system transforms non-standardized denial reasons into standardized parameters through mapping rules. Each payer-specific denial reason is converted into a standardized code and category, allowing the system to maintain adaptability to various payer policies while reducing processing complexity. This parameter transformation enables consistent analysis and reporting across different payers.
Solution Approach 2:
The patent creates a universal denial processing framework that can handle multiple payer-specific denial reasons through a single standardized system. The rules engine is designed to accommodate different payer policies and denial codes while applying consistent processing logic, thereby reducing overall system complexity and enabling standardized analysis across diverse payment scenarios.
3Device complexity
If monthly aging of receivables is used, then simplicity of the aging process is maintained, but accuracy of collection forecasting deteriorates
Solution Approach 1:
The system implements periodic aging at multiple intervals (daily, weekly, and monthly) rather than relying solely on monthly aging. This multi-interval periodic action maintains the simplicity of standardized aging categories while improving forecasting accuracy by capturing more frequent updates on receivable status changes, allowing for more timely and accurate collection predictions.
4Measurement precision
If dual account balance structure is used, then accuracy in tracking patient and insurance balances is improved, but system complexity and difficulty of management increase
Solution Approach 1:
The system segments the account balance structure into distinct patient and insurance sub-accounts within the overall account. This segmentation enables accurate tracking of each component balance separately while maintaining a view of the total account balance. The segmented structure is managed through automated rules that handle allocations and adjustments, reducing the perceived complexity for users.
Data Source
AI summary
A system for managing account receivables is provided. The system comprises a rules module or engine for receiving at least one encounter from a first party and for assessing the at least one encounter based on rules associated with a payer; and a transactions module or engine for outputting at least one claim to the payer based on the rule module's assessment of the at least one encounter.