How a New Breed of Software is Bleeding Providers Dry,
and How to Build, Buy or Demand Tools and Techniques
to Put a Stop to It 85 minutes; standard DVD format (NTSC, SD); chapter menu.
Includes accompanying CD-ROM with resource documents, live links to additional resources, and schematic of "Approval Driver" system for piercing payer armor.
Correct Coding Initiative Edits. Duplication of Services Edits. Bundling and Unbundling Edits.
Pretty familiar territory in the world of healthcare claims, right? They’ve got their edits; we’ve got our edits. Right?
Think again.
There is a new category of software tools that payers are bringing to bear on the adjudication process that is an order of magnitude more sophisticated than providers have faced in the past. So sophisticated that some of the vendors don’t even charge a license fee – they just collect a contingency on the millions of dollars that get stripped out of providers’ monthly checks. So deep and so broad is the technology that it allows the payer to set a tolerance level – what percent of outbound payments do you wish to retain? How much will your providers put up with?
It’s time to put a stop to it. We’ll show you how in this two-disk video set.
A Denial Engine runs in addition to and before the regular adjudication process – even before the payers’ own automated claims filtering systems. It can also be applied to claims history – capturing “overpayments” and deducting dollars from current remittances. And the engine has a throttle – throttle up the engine to engage more obscure edits to boost payer profits; throttle it down if providers get too peeved. Payers can now simply decide how much they want to pay out. Quarterly profits sagging? Deny more claims.
Is it legal? Is it ethical? Surprisingly, yes. Or at least they can be used within a legal and ethical framework. Denial Engines typically deliver automated defense documents that reference providers’ own practice standards and published sources, in addition to payer contract terms and payment policies. The unprepared provider may simply take these at face value, and decline to appeal. That’s the response these tools are designed to evoke.
For more than two years, Healthcare IT Transition Group has been researching the Denial Engine and closely tracking its evolution. Our research has captured the emerging picture of this new technology, and provided a framework for tools and strategies providers can use to implement against them. (IMPORTANT NOTE: We neither recommend nor promote particular vendors, products or services. Examples are provided, but it is not the purpose of this report to evaluate particular software offerings or services.)
The report reveals the systems and the economics involved, lays out a methodology for providers and software vendors, and provides a schematic overview of the Approval Driver, an application designed to pierce payer armor and get claims through to adjudication. The nonexclusive right to adopt or expand upon this design is included with your purchase.
Among the topics covered:
- How Denial Engines differ from traditional claims editing approaches
- Why payers are rushing to implement these tools
- FRAUD! (and abuse) vs. (fraud and) ABUSE
- Where Denial Engines enter the claims process
- Who are the players?
- Getting Claims Paid Despite DE
- “Approval Driver” – an exclusive HITTG design schematic you can use to develop an anti-Denial Engine system
Intended Audience
- Practice management software (PMS) developers
- Provider software vendors
- Revenue Cycle Management (RCM) specialists
- Provider Business Office Staff and IT Support
- Billing Service managers and executives
- Clearinghouse Provider Support Staff
Resource Materials and Tools
- Denial Engine Vendor Resource Sheet with links
- Denial Engine Clients and Partners – who is using this technology?
- Recovery Audit Contractors Intelligence Report
- Approval Driver – an exclusive HITTG design schematic
- Study guide handout in printable form
- Slides with live resource links
