Medical Necessity

inHealth offers the Medical Necessity Rules Engine (REaaS) as a service for payers which provides a complete solution: infrastructure, systems operations, software, the medical rule library, and the medical rules maintenance by an expert medical team.

REaaS is a fully compliant clinical rule engine solution that is integrated with the healthcare data exchange solution to increase the consistency of performing medical necessity checks across an organization in an automated fashion and ensuring the standardization of clinical rules applicable for a given clinical scenario while supporting multiple coding standards, including ICD9, ICD10, CPT4, HCPCS, CDT and the UAE Drug lists. Additionally, the solution has a high auto adjudication rate, which substantially reduces the number of full-time employees needed for medical adjudication. This in turn decreases medical costs. The uniformity and consistency of the medical necessity check will significantly decrease disputes and appeals with healthcare providers. Moreover, the solution also improves the cash flow by automated (faster) rejection of claims, reducing the need for 80% advance payments.

The engine has remained in a state of continuous evolution over the last 6 years, and is designed to reshape itself and adapt in order to support regional medical practices and to reduce disputes with medical providers resulting from the rejection of claims and resubmissions. The solution is service-based, which means that it can easily be integrated with core systems and other systems managing the process.

The medical necessity rules engine will perform standard checks for coding (CMS), pair checks, maximum daily allowance, age, and gender as well as medical necessity checks, utilizing internationally recognized best practices and evidence- based medicine, and performing ICD cross check for Labs/pathology, Dental codes, Consumables (HCPCS) and once-in-a-lifetime incidents.