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WORK SMARTER, NOT HARDER The RevRecover® Business Rules Engine

“Work smarter, not harder” is more than a tagline. Vortext Analytics’ RevRecover® Business Rules Engine drives intelligent workflow.

Choosing which Denials and Underpayments to Work

Knowing which denials or underpayments to focus on can be a daunting task. When discussing revenue cycle issues in healthcare, you will often hear, “We have lots of problems with denials and underpayments, we just don’t know where to start.”

RevRecover® clears the path for our clients with our business rules engine (BRE) which not only identifies (via rules you establish) what you consider to be an account to be worked, but also pushes it to the appropriate coordinator’s worklist – with no user intervention required.

Next as the appeal is worked, additional rules push it through the process automatically. Since RevRecover is a full cycle appeal, submission, and reporting tool, we update the record when new information (e.g. remit or adjustment) occurs.

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Client Benefits

What does this mean for our clients? Following a recent implementation, Vortext® examined legacy data from the client for the three most recent calendar years. Not only had the client left an average of over $1.6 million dollars per year unworked, but Vortext also discovered over 31,000 accounts the client had pursued in that three-year span that did not meet their definition of an appeal or underpayment. This was due to worklists being populated by manual queries that did not consider all relevant variables.

With an average cost of $118 per appeal, this amounted to over $3.7 million dollars in administrative burden. Use of RevRecover will allow the client to refocus these resources toward appealing the previously un-worked accounts.

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Claim Analysis

identifies commonalities and develops groupings for denials and underpayments. This allows clients to identify specific problem areas and address them in order to achieve better results at multiple levels including; average time to pay, plan, contract, and payer performance. ClaimAnalysis also provides data to assist in adjusting the business rules that drive RevRecover workflow.

ClaimAnalysis was developed with an existing client, building on that client’s research into denials around Zollinger-Ellison Syndrome (published as a use case). In addition to the client’s initial results, during ClaimAnalysis development an additional $1.3 million in un-appealed denials around HCPCS drug administration codes were revealed. This is typical of the research that drives development of Vortext® products.

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