nTelagent Announces New Solution for Medical Necessity Processing

NASHVILLE, Tenn.--(BUSINESS WIRE)-- nTelagent, Inc. has announced a new module for medical necessity processing for Medicare and other major payors at point of service, along with real-time scripting for patient-due collections. The new module is integrated with nTelagent’s current point-of-service solution for healthcare, which provides insurance verification, charity determination, payment processing and real-time scripts for the registrar.

An effective, properly run medical necessity program is more essential than ever with healthcare reform’s crackdown on fraud and abuse, along with the increasing importance for providers to know covered versus non-covered services and all accurate patient-due balances at point of service (e.g., patient-due portions for services not deemed medically necessary, in addition to deductible, co-pay and/or coinsurance).

nTelagent’s new module allows providers to process medical necessity upfront, complete Advanced Beneficiary Notice of Non-coverage (ABN) documentation when appropriate, immediately collect patient-due amounts, and comply with associated legal issues. Providers are required to issue ABN notices to patients/beneficiaries in situations when Medicare/payor payment is expected to be denied because the service is deemed medically unnecessary.

“With the current nTelagent system, our clients see tremendous cash improvement, reduction in denials and proper account processing. The new medical necessity module will allow hospitals to quickly complete ABN processing at pre-registration or registration, and, importantly, the new module is integrated with our current solution’s other point-of-service features,” explained Irene Barron, nTelagent COO and product management officer.

Often, medical necessity solutions are stand-alone systems that don’t integrate with a hospital’s existing processes or offer the ability for associated upfront collections. In addition, most medical necessity is determined outside the registration process, resulting in adjustments being made for non-covered charges once the insurance payor has paid.

Following real-time, customized scripts, a registrar using nTelagent’s system can tell a patient whether or not the procedure the physician ordered will be covered by the payor. Then, for those procedures not meeting medical necessity guidelines, nTelagent scripts prompt the registrar to print out the ABN form, obtain the patient’s signature, and collect appropriate payment due.

With nTelagent, patients receive accurate information regarding their financial responsibilities and insurance coverage, arming them to make knowledgeable decisions about their care.

nTelagent’s new medical necessity module offers hospitals the following benefits:

  • Decreases write-offs and bad debt and increases upfront collections
  • Automatically triggers ABNs and requests for signature
  • Allows for immediate processing of patient-due portions for services not deemed medically necessary, in addition to deductible, co-pay and/or coinsurance
  • Improves coding efficiency and prevents medical necessity denials from occurring in the first place
  • Minimizes legal and compliance concerns related to fraud and abuse
  • Maximizes staff productivity (reduces time spent researching denials)

Barron continued, “We’ve already seen major impacts from healthcare reform from the insurance carriers: Deductibles and co-pays are higher than ever. Going forward, we know providers will be paid less by payors, and the patient will owe more. It’s imperative that point-of-service collections – including those related to services deemed medically unnecessary – become a major focus.”

Inappropriate medical necessity practices result in Medicare and other payor denials, costing hospitals hundreds of thousands of dollars annually in write-offs, in addition to putting providers at risk for fines or other penalties. For example, writing off patient balances for denied claims may be considered an anti-kickback violation, and consistently billing non-covered procedures to Medicare without an ABN may be considered abuse according to the Office of the Inspector General (OIG).

The Obama administration’s focus on curbing fraud has resulted in the recovery of a record $2.5 billion from providers during the last fiscal year, with the goal of recovering an additional $4.9 billion from Medicare fraudsters over the next 10 years. Healthcare reform also contains provisions that enhance penalties for violations and expand the authority of the Recovery Audit Contractor (RAC) program.

Barron added, “nTelagent remains committed to assisting our clients in properly processing accounts at point of service, including complying with all federal and state regulations. Along with the other services offered by nTelagent, this new module takes our clients another step in that direction.”

About nTelagent, Inc.

nTelagent’s total point-of-service solution, the Retail Application for Healthcare, guides patient access staff through each patient encounter via real-time, customized scripts. From insurance verification to payment processing, registration is fast, simple and accurate for all patients: insured, uninsured and those qualifying for financial assistance. nTelagent’s clients increase upfront cash and cash on hand, reduce AR days and bad debt, reduce or eliminate back-end denials, and follow consistent practices on all registrations with just one system – for a fraction of the cost. Visit www.ntelagent.com for more information.


Laura Campbell & Associates
Laura Campbell, 615-579-6599
[email protected]

KEYWORDS:   United States  North America  Tennessee

INDUSTRY KEYWORDS:   Technology  Data Management  Software  Practice Management  Health  Hospitals