CRXIS – Our Business Intelligence Engine

Read Time:
2 Min

The Out-of-Network VS. In-Network world in healthcare is changing
Source: Wakefield
May 26, 2024

One of the biggest reasons for our success is what we call our CRXIS business intelligence engine. CRXIS serves as one of the largest out-of-network (OON) databases in the industry.

No other revenue cycle company has as much information on out-of-network as we do.

CRXIS - Our Business Intelligence Engine

CRXIS stands for Collect Rx Information System, the data and analytics tool we’ve created to counter-act the payers’ efforts to reduce payments on OON bills. This is our proprietary software we’ve developed to enhance payer reimbursements by automating AR Follow Up, maximizing out-of-network reimbursements, and providing analytics & reporting.

Many providers encounter issues with their revenue cycle because it’s a manual, time-consuming process.

They spend too much time identifying issues with AR rather than fixing them because they have to individually check every account’s 835 data.

They resort to spreadsheets or restrictive software to keep organized, and they have to make multiple calls on each account just to get the status.

CRXIS allows us to…

– Analyze actual insurance policies throughout the country to determine what is “reasonable and customary”. By analyzing these insurance policies, we are able to get a detailed understanding of plan types and language defining “usual and customary”. For example, they may want to pay 110% of Medicare, but the policy might say “reasonable and customary” is what similar facilities in the community charge. We don’t just rely on what the insurance company says. We go straight to the source.

– Maximize revenue is the workflow engine. CRXIS is a powerful tool that uses rules-based processing and AI to send claims to the right person at the right time for follow up. It identifies those claims with the highest likelihood to provide additional payments and sends them to our staff for follow up, ensuring that regardless of the volume of claims, we are working the ones most likely to impact revenue.

– Provides us with an incredible amount of comparable data because we’re aggregating data and results from the 3300+ customers that we service. We use data and analytics to compare our determination of R&C with the payor and, in many cases, we’re able to identify “holes” in their data and convince the payor to increase their payment.

CRXIS - Our Business Intelligence Engine

Our database captures business intelligence about the tendencies and trends of the people on the payer side. Our experienced team knows who to speak with at each of these companies and we have the ability to go to senior personnel at the payer who oftentimes are the only ones with the authority to approve higher payments to providers.

Where Does The Data Actually Come From?

We pull data into CRXIS from 3 sources:

First, CRXIS contains all claims we have worked for our 4500+ clients over the past 16 years. This includes over $1 billion in claims each year over the past several years.

Next, we ingest reference data sets available in the market, including but not limited to FairHealth, and Medicare data.
Then, we also pull in 837/835 EDI feeds and other payor remit data.

And best of all, we have robotic automation processes, or bots, that scrub payer websites to see how a claim is being adjudicated even before you receive the 835. This is essential to reducing denials and days to receiving payment. Account statuses will automatically feed into our system eliminating the need to follow up every 7, 10, 14 days because the bots are continuously pinging payer websites. And since we get statuses even before you receive the 835, we can be more proactive in working your accounts as opposed to waiting for them to hit your clearinghouse or waiting for paper EOBs.

Using all this information, CRXIS will assign our staff at-risk accounts through dynamic queues to quickly correct and prevent further AR deficiencies. Challenges to AR like denials, delays, and underpayments are automatically bucketed and sent for our staff to fix. Think about how many collectors it would take to do all of this manually. It’s virtually impossible!