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
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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 handouts in PDF format, slides in PPS format,
links to additional resources, schematic of "Approval Driver" system for piercing payer armor.
Catalog ID: DVD-DE0802A-0063
$395.00 USD
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 nearly 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: This is not a sales presentation. We neither recommend nor promote particular vendors, products or services. Examples are provided, but it is not the purpose of this session to evaluate particular software offerings or services.)
The presentation 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 paid registration.
Among the topics covered:
"One of the few people in the industry who can truly be called a leader in thought."
~Michael Apfel, Truman Medical Centers
Martin Jensen is Chief Analyst and a principal partner at Healthcare IT Transition Group, a consultancy whose clients include healthcare providers large and small, health IT software and service companies, and some of the nation's largest health plans. Recently, Marty has recently been involved in health IT remediation projects in state Medicaid, vendor and payer organizations. His seventeen years in healthcare IT include work in health plan remediation and provider outreach, engagements with software vendors in product development and systems design, and over fourteen years in business analysis and project management for provider organizations. In 2007 Marty was honored with the Workgroup for Electronic Data Interchange (WEDI) Distinguished Service Award.
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