Gesundheitswesen

Netcetera’s Claims Automation Processing Solution (CAPS) is the perfect solution to increase your decision accuracy, processing speed, and ability to prevent fraud.

Our system achieves fast processing because it removes uncertainty when making decisions. The combination of rules for medical necessity, policy benefits, and AI-based models for preventing waste, abuse, and fraud makes it a powerful decision-making engine. Your audit and reporting teams also get a full overview of the decisions, operations, and practices of all stakeholders.

Features:

Best in class medical necessity database from AAPC

Selection of localized drug databases

AI-based tool for fraud detection

Fully automated, end-to-end claim lifecycle management

Built-in audit reports and analytical insights

Flexible subscription model

In partnership with

Benefits

Improve the healthcare claims experience for your customers

Increase your productivity and throughput

Improve efficiency and reduce operational costs

Eliminate claim leakage

Free up your team’s time to focus on what really matters

Components/modules:

Claims management engine

Our claims management engine is at the core of the solution. The engine is based on Netcetera’s decade-long experience in processing healthcare claims for regulators and insurance companies. In partnership with Greenrain, we maintain and guarantee continuous compliance of the system with local regulations.

Features:

End-to-end integration with regulators or care providers
High throughput designed for large volumes of claims
Adaptable for various standards and custom rules
API interface for full insurance system integration and no-code customization

Medical necessity

The system seamlessly integrates the medical necessity rules from one of the market leaders in the industry, AAPC. In partnership with Greenrain, the medical necessity rules are compliant with the local regulation.

Features

Built-in medical necessity rules from AAPC
AAPC is the market leader in medical coding, billing, and auditing
All medical necessity rules are localized according to local regulations
Ability to override automated decisions based on the medical necessity rules

Detection of waste, abuse, and fraud

Netcetera’s own ML-based models detect waste, abuse, and fraud in healthcare claims. The system can identify deviation in behavior, in addition to adjudication and medical necessity rules. This module contributes a significant amount of trust in the decision-making process of the system because it prevents stakeholder behavior that is against the established norms.

State of the art Machine Learning models designed for healthcare claims
Risk scoring of individual claims, line items, and clinicians
Self-adaptive system that learns with each claim decision

Reporting and audit

The analytical module is based on our long experience in enabling regulators and insurance to act on the facts. It contains standard, ready-made reports which can be used for either reporting or audits.

Measures and reports standard operational indicators
Utilization reports for members and policies
Audit reports for providers, provider groups and individual clinicians
Flexible reporting engine for new reports and insights

Software as a service (SaaS)

The system is operated in-country on Azure and fully managed by Netcetera. You use the benefits without operational costs, with an appropriate commercial usage-based pricing model.