Enforcer Is Smarter Than You

Posted October 25, 2019 by Steven Stone

Complex claims are, well, complex – they’re labor intensive, have complicated reimbursement rules, and usually constitute less than 10% of the overall hospital business.  EnableComp has been an industry leader in this space for 20 years, and our secret weapon to cut through the complexity (i.e. get paid faster, more efficiently, and with a higher yield) is our proprietary reimbursement software platform, Enforcer.  Its abilities come from an algorithm-based rules engine (or “brain”) that’s able to accurately price any claim in any locality (including federal-level), and it’s getting smarter every day through machine learning

Wait, what is machine learning?  And more importantly, what does it mean to your complex claims? At a high level, machine learning is a method of semi-automated data analysis that identifies trends and makes decisions with minimal human intervention…translated: the computer gets smarter with each claim processed. EnableComp has developed statistical models to learn from our claim data, and we use machine learning to automatically process and add each claim to these models to feed insights back into Enforcer. Ultimately, machine learning is using old and new data to make processes smarter.

And how did Enforcer get so smart?  It’s had a lot of experience, $1.6B+ in collections to be approximate! For example, the typical health system sees less than 1,000 workers’ compensation claims a year under 1 or 2 fee schedules.  The Enforcer database has over 4M workers’ comp claims in every single US fee schedule representing over $7B in total reimbursements. Simply put, Enforcer has the advantage of aggregating payer behavior, denials management, and maximizing reimbursement by utilizing trends from more data than any independent revenue cycle department ever could, and it has the big brains to make sense of it all. Every claim loaded to our system is analyzed compared against hundreds of variables and added to our general data model. What this means is that 1) the model is constantly refining our best-in-class claim pricing to ensure the provider gets paid max value allowable and 2) creating workflow optimizations to ensure get your claims paid faster. 

Enforcer allows us to maximize collections and minimize aging for Day 1 outsourced claims, but did you know it also creates revenue enhancement opportunities for your existing business? With our zero-balance review product, Enforcer allows us to maximize collections on our partners’ closed claims. Every claim is priced and evaluated on many factors (jurisdiction, payer, claim age, CPT codes, DRG code…I’ll spare you the rest of the excruciating detail), then scored to identify the best opportunities for additional revenue from what is otherwise hard-to-detect missed opportunities for the normal PFS shop. Each claim that’s appealed for an underpayment/denial, successfully or not, is feeding valuable data to the machine learning model and helping it continually learn. The same insights are applied to our aged and troubled open account products. We’re able to take open claims with remaining balances, then identify the best practices to follow up with payers to successfully get you every dollar you’re owed. These models and analytics aren’t just theoretical insights – we’ve used this data to collect over $250M in additional revenue for our clients.

EnableComp uses knowledge and insight garnered from Enforcer to maximize your complex claim reimbursement, and we provide these advanced analytics via reports and insights back to our clients. In addition to extremely detailed information about the current state of your complex claim business (more than you’ll ever want to know!), we also share evidence related to root cause analysis of denials, underpayments, and other potential shortfalls we observe in the claim data. For example, if a higher than average number claims are being appealed for underpayments, Enforcer can analyze the claim data to determine if potential issues exist in coding or registration that can be fixed going forward. The advanced analytics from Enforcer can identify problems before you even know you have them…and also provide the fix! 

Analytics have already made a huge impact on the clinical side of healthcare, and now they’re changing revenue cycle with EnableComp at the forefront.   Our unique machine learning platform (plus years of complex claims experience) helps us deliver best-in-class service maximizing Day 1 collections, enhancing revenue for open & closed existing AR, and fixing process issues previously unknown.  Our advanced analytics take the complex out of “complex claims” and help make your revenue cycle management, well, simple.