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Myndshft Blog

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October 4, 2019

How A Payer Rules Library Can Bring Order to Chaos

by Patrick | Healthcare Technology

Dance stepsImagine that you’ve been recruited to be part of a dance routine.

You arrive at the first rehearsal and meet the other dancers. The instructor strides in and introduces herself, then describes in intricate detail how the dance will be choreographed. After several hours of practice, you are starting to hit your marks.

When you arrive for rehearsal the next day, however, there is a new instructor.

He incorporates some of the previous instructor’s choreography but it is by no means the same dance. He adds new material and changes some important sequences. You stumble through the new routine but start to get the hang of things by the end of rehearsal.

You arrive the next day and — you guessed it — there is yet another new instructor and she has a completely different interpretation for how she wants to choreograph the dance.

This is akin to how it feels for revenue cycle teams at healthcare providers when they submit claims to payers 

Payer rules governing medical necessity, prior authorization requirements, and any number of other coding and billing guidelines differ from carrier to carrier and are constantly changing.

Some of these changes are due to the workflow and adjudication idiosyncrasies at each insurer. Some are due to changes within the larger healthcare landscape that impact payers and providers. For instance, when new HIPAA regulations get introduced, or when a new coding standard like ICD-10 is instituted to replace a previous version.

Regardless of the reason, payer rules are a moving target.

And because there is no standardization of these rules from payer to payer, revenue cycle personnel are often left to improvise stopgap solutions.

  • Some will create a mosaic of sticky notes with the payer rules for each insurance company scribbled down.
  • Others will aggregate the payer rules into an Excel spreadsheet template like this one.
  • Some will even assign team members to be the resident experts for particular health plans.

The problem with these kinds of makeshift solutions, however, is that they still don’t address the fact that payer rules are always fluctuating. As a result, your sticky notes and spreadsheets are often obsolete the minute you start referencing them. And the tribal knowledge that a team member may have regarding a particular health plan walks out the door when she leaves for vacation or another job.

These kinds of payer rules workarounds aren’t integrated with a provider’s existing EMRs, LIMS, or financial management systems either. And they definitely don’t work in real-time. So medical billing teams are still left to manually cut and paste from one source to another, wasting valuable time.

Automating Payer Rules

To realize our mission to automate and streamline healthcare administration, Myndshft realized early on that we needed to create a payer rules library that addressed the shortcomings of existing workarounds.

We’ve accomplished that by developing an extensive payer rules library and pairing it with a self-learning rules engine that constantly updates eligibility and prior authorization rules for over 700 payers. Myndshft dynamically updates automated workflow and rules engines based on the actual responses and results from submitted prior authorizations. So the more you use it, the smarter it gets.

About Myndshft

Myndshft is a software-as-a-service that automates and simplifies time-consuming healthcare administrative tasks associated with prior authorization, eligibility verification, and patient financial responsibility, freeing providers and payers to concentrate more fully on patient care again. Myndshft was founded in 2015, and works with leading providers, payers, and health information exchanges.

See Also

Why Automation is the Key to Fixing Prior Authorization

Claims Denial Prevention in an Age of Prior Authorization

Related Terms

Medicaid, Medicare