Automated Guidelines Healthcare Reimbursement Series Reducing friction in the reimbursement process is an important challenge faced by healthcare organizations today. Many of them are looking for technology to reduce inefficiencies and cut costs while improving the visibility of integrated patient and clinical data. Trisotech addresses the issue with an easy to use business modeling and automation platform. Business modeling and automation is a mature technology based on open standards that has proven its value in a wide range of industries. In healthcare, it enables clinical, business and IT personnel to collaborate in a visual environment to document, communicate and automate healthcare guidelines. The technology can be integrated with hospital information systems using FHIR and CDS Hooks. Automating these complex workflows can improve efficiency, allowing resources to be allocated to more challenging problems. Issues can be identified and resolved in real-time with the logic underlying all decisions transparently available to the organization. To illustrate the capabilities of business modeling and automation for healthcare reimbursement, we will demonstrate how it can be used by payors and providers alike in a series of three webinars. Preauthorization for Targeted Drug Therapy and Streamlining of the Appeals Process Targeted drug therapy can be very expensive, and insurance companies do not want to pay for it when it is not indicated. In the second webinar, we will discuss preauthorization for targeted drug therapy using Rituximab as an example. We will show how business models can streamline the appeals process for both the insurer and the provider. Analysis of the data can give insights that can result in process improvements.

1. Automated Guidelines
for Healthcare
Reimbursement Series
Three FREE Online Presentations/Micro-Events
Dr. John Svirbely, MD
Chief Medical Informatics Officer (CMIO),
jsvirbely@Trisotech.com
Denis Gagne
Chief Executive Officer (CEO),
dgagne@Trisotech.com

2. Automated Healthcare Reimbursement
Guidelines Series
1. Orthopedic Surgery Preauthorization (Sep 30)
2. Preauthorization for Targeted Drug Therapy and
Streamlining of the Appeals Process (Oct 21)
3. Documentation of Medical Necessity for CMS
Home Services (Nov 18)

3. Some logistics
1. Recording and slides will be
made available to all
attendees
2. Q&A – Send your questions in

4. Healthcare Reimbursement
authorization (as by an insurer) that is required prior to or after
the performance of a health-care service (such as a surgery or
prescription of a drug)
involves a series of processes to determine if a patient has
insurance coverage for a healthcare service or good . A healthcare
service or good without preauthorization, or medical necessity, is
normally not paid for by the insurance company
https://www.merriam-webster.com/dictionary/pre-authorization

5. Automatable
Guidelines
An Automatable Guideline is a visual decision
model that is both human readable and machine
automatable.
Such a standardized workflow can improve the
efficiency and quality of healthcare processes.

6. Our Objective
Promote the modeling of Automatable
Guidelines using open standards to:
• Disambiguate Guidelines creation and
interpretation
• Inform care coordination workflows
so that:
• Clinical Knowledge is delivered at the point of
care
• A single visual Knowledge Artefact is created for
clinicians and for automation

7. Benefits
Payer
•Effectiveness: Complete and correct information at submission
•Efficiency : Increased decisions throughput
•ROI: Reallocation of resources
Patient
Necessary care with minimum delay
Reduced stress and anxiety
No incurred financial surprises
Provider
Real time adjudication
Clear understanding of the acceptance criteria
Lower administrative burden

8. Marrying two sets of standards
www.OMG.org www.HL7.org

9. Established to foster the sharing and
promulgation of best-practices
around modeling and sharing:
• clinical pathways,
• clinical guidelines, and
• other healthcare knowledge
A robust and thriving community-
of-practice of healthcare
institutions, professional societies,
and vendors
www.BPM-plus.org

10. OMG BPM+ Standards
Open standards for: 1) machine interpretable models based on 2) unambiguous graphical
notations visual languages (MN)
Language Provides Examples
BP (Business Processes) MN Process diagram
(Prescriptive)
Flow diagram, guideline
CM (Case Management) MN Unstructured
processes
(Declarative ECA)
Personalized patient care
D (Decision) MN Decision
(Stateless)
Decision tables, logical
expressions
www.OMG.org

11. Overview

12. Preapproval of Targeted Drug Therapy
Modern therapies using humanized monoclonal antibodies are
very expensive.
A monoclonal antibody is a cancer treatment that enlists natural immune system
functions to fight cancer, i.e. it stimulates the body's immune system to fight cancer
cells.
Some have therapeutic use beyond the conditions for which they
have regulatory approval.

13. Cost of Targeted Therapy – Two Examples
Targeted Drug Brand
Name
Target Cost per Year
rituximab Rituxan CD20 $33,000
pembrolizumab Keytruda PD-1 receptor $110,000

14. Approved Indications (”On Label”)

15. Rituximab Therapy (”On Label”)

16. Submitting an Appeal for Off Label
Usage
• The details of the process vary between insurers.
• This is expensive since it requires review by clinicians working
for the payer.
• It usually requires submission of evidence justifying its use,
which may be of varying quality.

17. Levels of Evidence of Efficacy for
Off Label Use
No
Evidence
Weak
Evidence
Some
Evidence
Good
Evidence
Approved
Off-Label
Appeal
worthy
Clinal trial
worthy
On-Label
Desired Usage?
Evidence of efficacy?
Potential Outcome?
Rejected

18. Required Evidence (“Off Label”)

19. Off Label Drug Request

20. Nonstandard Evidence of Efficacy

21. Off Label Drug
Use
Demo

22. Introducing AI

23. Conclusion
Combining OMG BPM+ standards with HL7 standards provides:
• An automated way of confirming On Label drug use
• An automated way of appealing and reviewing Off Label drug use
• Standardizing preauthorization while reducing the burden of
human review
Over 900 Automatable Guidelines (Models) are openly available here: https://cds.trisotech.com

24. Any questions?
THANKS!
Recording and slides will be made available to all attendees at www.Trisotech.com