Preauthorization can be a source of stress for patients and providers. It is difficult to keep up with the changes made by different insurers, and there is the threat of criminal prosecution. In the first webinar, we will give an example of a routine preauthorization for an orthopedic surgical procedure - first total knee arthroplasty. The burden for providers can be reduced by integrating preauthorization with models used to prepare the patient for surgery.

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. Abstract
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.
Orthopedic Surgery Preauthorization
Preauthorization can be a source of stress for patients and providers. It is difficult to keep up with the changes made by
different insurers, and there is the threat of criminal prosecution. In the first webinar, we will give an example of a routine
preauthorization for an orthopedic surgical procedure - first total knee arthroplasty. The burden for providers can be
reduced by integrating preauthorization with models used to prepare the patient for surgery.

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 health-care service . A health-care
service without preauthorization or medical necessity will not be
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. 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

9. Introduction to BPM+
Open standards for machine interpretable models based on unambiguous graphical
notations visual languages (MN)
Language Provides Examples
BP (Business Processes) MN Process diagram Flow diagram, guideline
CM (Case Management) MN Unstructured
processes
Personalized patient care
D (Decision) MN Decision (trees) Decision tables, equations
www.OMG.org

11. Healthcare specific standards
A service that is invoked by the EHR via a Hook, evaluates its own
logic using FHIR data and returns decision support via Cards
Automate healthcare data sharing and improve patient care
www.HL7.org

12. International Open Standards Used

13. Orthopedic Surgery Preauthorization
Preauthorization involves a series of processes to determine if a patient has insurance
coverage for a medical intervention. A surgical procedure without preauthorization will not
be paid for by the insurance company.
BPMN and DMN are open-source, standards-based modeling tools for representing
processes and decision-making. They have been used for decades in various industries to
automate tasks and improve efficiency. Our goal is to show how these tools can be used to
automate processes in preauthorization.

14. Key Processes in Preauthorization
In most cases preauthorization involves a straightforward approval or denial
for an intervention that does or does not meet specific criteria that represent
the standard of care.
Some patients do not fit into standard categories and require special
consideration. These patients may be denied on routine review. For these
patients there is an appeals process where a provider submits additional
information to justify the request. The insurance company then decides to
approve the appeal or not.

15. Guidance for Routine Preauthorization

16. Preauthorization Workflow Pattern
Trigger
Outcomes
Branching
Choice
Behaviour
Tasks

17. Total Knee Arthroplasty Initial

18. Diagnostic Criteria for Severe Disease

19. Decision table

20. TKA
Preauthorisatio
n Demo

21. Conclusion
• Surgical preauthorization can be automated with BPMN and
DMN models.
• This preauthorization automation benefits Patients, Payers and
Providers.
• These models can further be integrated with other models, for
example preoperative assessments.

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