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New Tech for Health Systems can Number-Crunch its Way out of Denied Claims

Portrait of a senior businessman working on computer at the office.The Industrial Internet is fast becoming a cornerstone of modern healthcare. It now provides clinicians with the missing links between information and the patients who can benefit the most from it.

Arguably, the environment that is advancing the most with the Industrial Internet is hospitals. Healthcare professionals across the board are using shared data to work better, faster and smarter. In today’s healthcare landscape, the ability to provide better patient care hinges on the ability to understand and translate vast amounts of information into better performance.

For many patients in the US, negotiating the labyrinth of healthcare payments can be daunting. Not only can the healthcare system leave patients out of pocket via large and unexpected payments, but changes to health plans and payment models can also be costly for health organizations too.

A mostly private, insurance-based system ensures patients have help paying for the care they need, but it is often the case that patients and health organizations alike will be denied reimbursement by insurance companies.

Patient confusion often stems from a misunderstanding of complicated policies that change frequently. For health systems, the sheer volume of newly insured patients and plans make the task of maintaining financial performance a herculean endeavor.

As healthcare in the US shifts to a value-based system, and the cost of healthcare shifts to patients, health organizations must not lose focus on managing payments with commercial and government payers, or risk financial hardship, as they still represent the majority of healthcare revenues in the country.

Within the vast patchwork of networks, deductibles, copays and coinsurance that makes up the US healthcare system, the reason why a claim is denied is rarely crystal clear. According to AARP, 200 million claims are rejected every year, and for a wide range of reasons. Identifying exactly why a claim was denied is alone a costly struggle: gathering additional information can cost up to $25 per denied claim.

Given the proper tools, many of these denied claims could be recovered. This is where the power of the Industrial Internet comes in.

Built on pre-existing analytics software, GE Healthcare worked with its customers WestMed Practice Partners, Orlando Health and UC Irvine Health to develop a new solution, DenialsIQ, which cleverly analyzes claim information, helping healthcare administrators identify and act on trends that are shown to lead to claims denials.

GE Healthcare DenialsIQ_PULSE

The software picks out trends in claims denials, enabling healthcare professionals to spot patterns and manage claims more efficiently.

“Our challenge was that the trends we were working took too long to define and usually didn’t pay off, even if we fixed them,” said Jose Rivera, Corporate Director, Physician & Professional Services, Orlando Health, one of the organizations that helped with the development of DenialsIQ.

Using algorithms (which are patent pending), the software gives health organizations the power to spot previously hidden trends in denied claims in order to address issues at their root cause and in bulk, which changes the way claims are processed, and helps avoid future denials.

Few have explained predictive software platforms as well as Dave Bartlett, chief technology officer of GE Aviation. Speaking to GE Reports last year, he likened them to the physical train platforms at a rail station.

“It’s a safe, secure, efficient and reusable structure that allows you to easily board a train,” he said. “It’s also very scalable, allowing a single rider as well as a crowd to get on and off. […] Without a platform, getting on the train would be pretty dangerous and it would require a lot of effort. It would be different every time, depending on the speed of the train and whether there is someone waiting to pull you up.”

Carrying this analogy over into healthcare, DenialsIQ helps administrators keep track of denied claims without having to start the process from scratch each time. The platform can also be implemented in many other health systems around the country.

“As the value-based care movement takes hold, the healthcare industry is reaching a tipping point, where operational excellence becomes a pre-requisite for a provider’s longevity,” said Jan De Witte, President & CEO Healthcare IT. “Technology can be the catalyst that enables providers to deliver better patient outcomes, while managing their operations.”

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