• InRule® for Healthcare

    Ensuring Consistent Decision-Making and Decisive Results throughout the Healthcare Revenue and Care Cycles

    Decision Logic and Business Rules

    Decision logic is the underlying code that is used to automate business processes. For example:

    • Underwriting decision logic includes risk assessment rules and other calculations
    • Health plan decision logic includes the rules that determine coverage and co-pays
    • Population management decision logic includes the rules that define a population as well as the resulting actions

    When decision logic is “hard coded” (written in program code by developers) it is difficult to share, time consuming and expensive to change.

    Business Rules are used to separate important decision logic from the rest of the application code, making it easier to update, manage and share across applications.

    In most healthcare organizations, business rules and decision logic are siloed across separate systems, potentially resulting in inconsistent decisions made in every area of healthcare – from underwriting to pricing, from benefit verification to reimbursement, from case management to treatment plans.

    InRule enables decision logic to be shared and managed across applications and platforms, ensuring consistent decision-making throughout the healthcare revenue and care cycles.  

    Healthcare applications are built using InRule for Healthcare. 

    • Author custom rules and update them easily, without custom programming
    • Easily integrate and interoperate with existing and new applications
    • Manage rules across applications with flexible, powerful rule management

    InRule Powers Healthcare Solutions

    For Plans and Payers

    InRule provides the foundation for reimbursement rules to be managed consistently throughout the reimbursement cycle, delivering cleaner claims and faster payments for physicians, payers, and clearinghouses.

    More information for Plans and Payers 

    For Providers

    InRule helps manage and automate the rules that govern the complex and changing relationships between data, such as test results, population characteristics, and protocols.

    More information for Providers 

    Case Study

    “Now, we can use the business rules engine to drive specific contract behaviors for every case we process. We can enforce specific rules, and if a problem comes up, the system provides specific information to people about what’s needed to solve the problem.”  

    Jason Rosenberg, VP of IT and Application Development, Access MediQuip  

    Read the Case Study 

    Additional Resources

    MS HUG
    InRule Technology is a Corporate Sponsor of the Microsoft Health Users Group.  

    Request a White Paper: Improving Decision-Making Interoperability and Consistency for Health Insurance Plans with Business Rule Technology

    Technical Product Information: Read more online about how InRule works

    Download Free Trial

    Recorded Demonstration: "Healthcare Rules! Using Rule Technology in Healthcare Systems"

    Watch the Video    

    HMO Product Customization

    The U.S.’s largest not-for-profit health plan offers dozens of basic HMO plans in each of the 10 states it services, with custom co-pay rules for organizational clients. Each HMO plan has more than 450 rules that determine co-pay rules, which are defined by treatment and in relation to one another. Clients want to determine co-pay rates for various services and the Health Plan’s representatives want to easily create custom plans for clients, while complying with co-pay rules.

    A Rule-Enabled Approach enables the Health Plan’s representatives to quickly and cost effectively offer clients customized co-pay plans that comply with internal rules. InRule provides a way for co-pay rules to be updated as necessary.

    Go to top 

    MDS 2.0

    "The implementation delay stems from concerns that the original start date did not provide enough time for software vendors, state agencies, and other systems to properly prepare for the MDS 3.0."

    Rena R. Shephard
    Founding Chair & Executive Editor, American Association of Nurse Assessment Coordinators
    President of RRS Healthcare Consulting Services in San Diego, CA.

    Minimum Data Set (MDS) is a tool used by skilled nursing facilities to assess residents and determine Medicare payments. Because MDS 2.0 rules were hard-coded in many applications, vendors and agencies could not quickly change their applications to support MDS 3.0. is rigid approach to rule management led to the delay of MDS 3.0 a full year to October 2010. Vendors, state agencies, and facilities planning for the upgrade to MDS 3.0 can benefit from using InRule to externalize the MDS rules that govern the questionnaires providers use to assess patients.

    Go to top 

    Claims Processing

    One of the top claims management services in the United States processes 250 million claims annually, with 500 million revenue cycle management transactions overall.
    An InRule Powered Claims Processing Solution:

    • Helps automate creation of payer files from claim files, streamlining the claims process
    • Enables easy updates to reimbursement rules without custom programming
    • Delivers first-time pass yield for claims of 98% (significantly better than the industry average of 90-92%)
    • Provides better performance than the hard code it replaced!

    InRule can provide the foundation for reimbursement rules to be managed consistently through the reimbursement cycle, delivering cleaner claims and faster payments for physicians, payers, and clearinghouses.

    Go to top