Clinical and Coding Logic Audit Solution Now Offered Stand-Alone
INDIANAPOLIS (November 29, 2017) — Equian, a leader in innovative Workers’ Compensation bill editing and auditing initiatives, announced today a stand-alone incremental clinical and coding audit solution (“Equian’s Clinical & Coding Logic Solution”). The solution is compatible with any bill processing platform and delivers the most comprehensive and best-performing Workers’ Compensation payment integrity solution available in the market. Equian has gained the respect and trust of many organizations in the Workers’ Compensation industry with its outsourced Bill Review, Rx, and DME solutions. Most recently, the company has worked with market leading Workers’ Compensation carriers to integrate its clinical and coding incremental value proposition. After years of including the incremental logic in its outsourced bill review solution, the company has developed a non-disruptive stand-alone model that can be added to any bill review platform without the need for system integration or utilization of valuable IT time.
Equian’s Dr. Anthony Pelezo, Chief Medical Officer and President of Reimbursement Policy, and Rhonda Miller, Vice President of Audit Operations and Strategic Initiatives, worked alongside key Equian IT and Operations personnel – combining hundreds of years of collective coding and reimbursement experience – to develop the stand-alone model. The R&D team utilized Equian’s big data repository of medical bill data combined with the continuous cycle of healthcare pre-payment and post-payment data mining and analytics to formulate a unique set of 100+ industry-leading rules.
Dr. Anthony Pelezo stated, “Workers’ Compensation has unique challenges when it comes to the necessity of proper bill management, from ever-tightening payment integrity controls to continuous changes in coding and reimbursement guidelines. These factors make it imperative for Workers’ Compensation payers to maintain tight oversight and control of payment, which is why we built an easy-to-use data exchange interface that works with any bill review platform. This allows clients to continue their own editing concepts and send what’s left to us to augment them with Equian’s 100+ proprietary rules. We then simply re-route bills back to our client’s platform for finalization of payment.”
Rhonda Miller added, “Our Clinical & Coding Logic Solution is flexible, customizable, scalable, and independent from the bill review engine. The incremental auditing logic works in tandem with a client’s medical bill review program to optimize savings before passing a bill to us for evaluation. We understand that large Workers’ Compensation payers have internal bill review processes and custom business rules to prevent payment leakage. We are not trying to replace those but rather to use over 100 incremental rules to further stop leakage.”
Scott Gullett, President of the Workers’ Compensation Division of Equian, further offered, “As a result of our experts’ deep dive, we found significant gaps in complex coding and editing logic and a complete absence of post-payment review and pattern detection logic that are a critical part of the payment integrity chain, so we developed the Equian Clinical & Coding Logic Solution to fill those gaps. The solution is also built into Equian’s service bureau bill review program, but is now an option for everyone.”
A few examples of incremental rules developed include Anatomic Joint Space Logic, Workers’ Compensation Enhanced Compensability Reviews, Expanded APC Packaging, Trauma Activation Standards, and many others. A video explaining the solution functionality and process can be accessed through the link below:
Equian is a leading end-to-end payment integrity organization. The company manages over $300 billion in claims data annually on its innovative platform designed to assist clients by avoiding, identifying, pricing, analyzing clinical codes, and ultimately recovering inaccurate transactions in the complex environments of healthcare, Workers’ Compensation, and property & casualty markets. Equian acts on data to pay the right party, the right amount, at the right time delivering over $2 billion annually in actionable savings throughout the payment spectrum.
Mike Morrison, CRO