Administrative

Revenue Cycle Management

Claims Clearinghouses serve as an intermediary between healthcare providers and insurance payers, ensuring that claims are error-free and in the correct format before submission. These entities streamline the claims process by converting non-standard healthcare data into a standardized format, facilitating electronic data interchange (EDI), and ensuring compliance with HIPAA regulations. By performing "claim scrubbing" to minimize errors, clearinghouses help to accelerate the reimbursement cycle, reducing denials and improving the efficiency of the healthcare billing process.

Claims Clearinghouse

Clinical Documentation Integrity (CDI) focuses on the accuracy and completeness of patient records to support high-quality care, continuity of care, and proper reimbursement. These products aid providers in capturing detailed and precise documentation of patient care, diagnoses, treatments, and outcomes. They often include features for real-time documentation guidance, automated review and flagging of discrepancies or missing information, and support for adherence to regulatory and billing requirements. By enhancing the quality of clinical documentation, these products support improved patient care, facilitate compliance with health regulations, and optimize reimbursement.

Clinical Documentation Integrity

Eligibility Checking products provide healthcare providers with tools to verify a patient's insurance coverage, including in-network status and covered services. They can also assess the cost of procedures in advance, enhancing transparency. Some of these products support the creation of Good Faith Estimates (GFEs), aiding patients and providers in making informed financial decisions regarding care.

Eligibility Checking

End-to-End Revenue Cycle Management (RCM) refers to the full set of processes associated with ensuring providers are reimbursed accurately and in a timely manner. Solutions in this category cover the majority of the functions across the revenue cycle. This includes: (1) front-end processes, such as eligibility verification and pre-visit patient payments, (2) mid-cycle processes, such as medical coding and claim creation, and (3) back-end processes, such as claim submission, payment posting, and denials management.

End-to-End Revenue Cycle Management

Patient Billing and Collection products are designed to streamline the patient billing process for healthcare providers, enabling them to issue accurate bills through the patient’s preferred channels. These products can offer various financing options to assist patients in making timely payments, enhancing the efficiency of collections and improving patient satisfaction with the billing process.

Patient Billing and Collection

Prior Authorization products serve as a bridge between healthcare providers and payers, streamlining the authorization process for treatments and medications. These tools facilitate the submission of clinical documentation by clinicians, making it easier for payers to review and authorize necessary procedures. On the other side, payers benefit from organized systems to manage and respond to treatment requests from healthcare providers efficiently. AI and machine learning, are increasingly employed within these products to assess the relevance and necessity of treatments, as well as to generate the prior authorization submissions themselves.

Medical Coding