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.
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
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.
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.
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.
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.
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.