The CORE engine is the backbone of the Medata bill review application. The engine processes bills according to the specific jurisdiction applicable fee schedule or UCR value, PPO Network contract rate, prevailing billing guidelines and client defined business rules without any human intervention, making it a truly automated process. Our business rules engine featured within CORE allows users to create client specific rule sets that are stored and applied to all bills further enhancing the automation review process. What sets this rules engine apart from others in the industry is its ease of use. This was designed with the user in mind. Each of the elements necessary to perform bill review is available as a building block for the user to choose from when creating a specific business rule.

Medata’s Adjustor Toolbox application is a web-based, workflow management system designed to allow users to access bills and perform a variety of functions, including approving a bill for payment or sending a bill out for external review. Additionally, since Adjustor Toolbox utilizes a relational database to store all bill review information, it serves as a powerful reporting tool. Adjustor Toolbox was designed for the claim representative to adjudicate, route, and easily work provider bills from any location. Through Adjustor Toolbox, the client can establish, automate and manage its preferred bill review workflow, based upon user-defined business rules. This robust workflow engine enables the client to determine its own level of aggressiveness in managing medical costs. Every step of the medical bill adjudication and payment process can be automated and monitored.

Adjustor Toolbox also facilitates physician and hospital bill reviews during the retrospective review process. The client would also have the ability to request peer reviews, either manually or in an automated fashion, based upon defined utilization criteria. The peer review personnel will receive the billing history, specific Medata utilization reports, and, if the client uses the imaging functionality, the medical records. Upon completion of the review, the peer review recommendations will be loaded into the Adjustor Toolbox for the client's review. Rules can also be set to impact payment decisions for future bills, based on the peer review.

In addition, Adjustor Toolbox is especially helpful in researching claim history and monitoring potentially fraudulent practices. Adjustor Toolbox builds on the strengths of our Procedure Analysis Report (PAR) and Advisor functions by incorporating both into the system. Together, these functions allow the user to compare a particular bill with bills previously submitted by all providers. This security-compliant application also provides real time, on-line management reporting to ensure jurisdiction-related on-time processing.