EagleForce Associates has licenced a patent pending claims/benefits Business Activity Monitiorning
(BAM) and Paperless Automatic Adjucication, Denial and Re-Classification (PADRE℠) claims processing
system, which utilizes a combination of rules-based analysis, algorithm and statistical based
technology, and methods to perform pre-payment predictive analytics and modeling to both identify
Fraud Waste and Abuse and to determine the efficacy of medical claims. Additionally, PADRE℠
examines content from historical claims and organizational data along with comercial data to
establish relivant data and to accurately adjudicate medical coding and claims. PADRE℠ is further
designed to statically track patient outcomes. The system software is scaled to process well over
1.2 billion claims each year, submitted from more than a million health care and equipment
providers whose PADRE℠ Profile extends 12 times more extensive than the standard CMS profile
through the use of current commercial data. Processing is "Cloud Capable" and takes place on an
integrated platform whose mission specifically targets accurate claims adjudication (validation of
claims and detection of fraud, waste, and abuse), reduction of paper, and elimination of human
intervention. The system has been demonstrated on actual CMS controlled data, having processed Part
A and B data for all claim types.
The PADRE℠ software platform is designed to reduce the complexity associated with servicing the
complex Fee –for- Service (FFS) enterprise which is made up of numerous payment systems and meets
all Federal Standards for processing and information security. PADRE℠ is effectively able to
adjudicate large volumes of coded transactional data along with queries from pre-processed claims.
The enterprise system delivers “Accept/Approve, Deny, or Re-Classify” signatures to the associated
record in a paperless automated fashion, thereby allowing the management and monitoring of the
decision making process to become completely seamless and equally administered without bias to
claim size. The system uses an Artificial Intelligence “Feedback Loop” to “Learn” from manually
processed and adjudicated claims.