From clinical episode to settled payer claim — the revenue cycle, engineered into one engine.
Multi-payer eligibility validated at admission against named payer portals. DRG/GRD grouper parameterised per market and embedded in the data tier — no middleware between grouping and billing. Version-controlled liquidations with full audit history. Claims emitted in each payer's required format on each payer's submission calendar. Denial management and the appeal cycle in the same surface as the original claim. Pre-billing medical audit integrated before submission. Automatic ERP synchronisation: every issued invoice lands in accounts receivable and starts the accounting circuit.
Coverage validated at admission, not at billing
Real-time eligibility check against payer portals at the point of admission — SITEDS for EsSalud Peru, SuSalud (Peruvian healthcare regulator), SEOGA for Sanitas Spain, CASS in Andorra, private insurer portals (Adeslas, DKV, Asisa, Sanitas, Mutua Madrileña). Multi-cover episodes — MUFACE/ISFAS state-employee co-insurance, Latin American obras sociales overlays — resolved at the rules engine before the clinical record opens.
Version-controlled liquidations
Every adjustment to an issued liquidation creates a tracked new version. Items added, modified or removed are recorded with user, date and reason. The auditor's question — what changed, who changed it, and why — is answered as a query against the version history, not as a manual review of correspondence.
Claims in the payer's format, on the payer's calendar
Claims emitted in the format each payer requires: TSI for the Spanish public-health surface, X12 837 equivalent for international payers, payer-proprietary formats for private insurance. Submission cadence per payer's calendar — weekly, monthly, per-event. Settlement reconciled at the claim line: accepted, denied, partial, contested.
Pre-billing audit, not post-denial reconciliation
Medical audit integrated into the billing workflow before submission. Inconsistencies between clinical activity documented in the HIS and services presented for billing are detected and resolved before the claim leaves the system. Denial rate reduced at source — not managed after the fact.
The revenue cycle, named at each surface.
Six first-class concepts in the billing engine — each parameterised, version-controlled, auditable. The episode is the unit of work; the payer is the rules context; the claim is the audit envelope.
Eligibility and multi-payer coverage rules
Coverage validation at admission against named payer portals: SITEDS for EsSalud Peru, SuSalud, SEOGA for Sanitas Spain, CASS Andorra, and the private insurer portal network (Adeslas, DKV, Asisa, Sanitas, Mutua Madrileña). Each payer's rules — co-payment schedule, deductible structure, excluded procedures, forfait packages, discount models — are rows in the engine's metadata repository, not custom code per customer. Multi-cover episodes (MUFACE/ISFAS state-employee co-insurance, Latin American obras sociales) resolved at the rules engine: which payer adjudicates first, what the secondary overlay covers, what the patient's residual obligation is.
DRG/GRD grouper at the metadata tier
Episode-to-DRG mapping parameterised per market and embedded directly in the data tier. Spanish AP-DRG, German G-DRG and Latin American DRG variants are each a configuration of the same engine — not separate hard-coded implementations. Case-mix index reported per hospital, per service, per quarter. Per-DRG payer rate by contract. Length-of-stay outlier classification at the engine. No middleware layer between the grouper and the billing surface; the DRG the episode resolves to is visible at every subsequent step in the cycle.
Version-controlled liquidations
Two automatic liquidations per patient episode: one to the insurer (valorización), one to the patient. The rules engine applies the full tariff logic — commercial conditions, coverage plan, co-payment, deductible, forfait, discounts and exclusions — to both. Every subsequent adjustment to an issued liquidation creates a new versioned record: items added, modified and removed are recorded with user identity, timestamp and reason. The valuation history is permanent and audit-reconstructable for any point in the episode's life.
Claims generation and payer settlement
Claims emitted in the format each payer requires — TSI for the Spanish public-health surface, X12 837 equivalent for international payers, payer-proprietary EDI for private insurance — on each payer's submission cadence. Settlement reconciled at the claim line: accepted, denied, partial, contested. Denial reasons categorised and surfaced in the denial-management workflow; the appeal cycle generates a derivative claim linked to the original by reference. Case-mix, denial rate and revenue-per-DRG metrics reported per service and per payer, available to the finance director without an IT request.
Patient invoicing with multi-cover logic
The patient's portion calculated after each payer's adjudication, against the contract terms of every cover in play. Co-payment per contract, running deductible per patient per payer, out-of-pocket maximum, lifetime cap, secondary-payer overlays for state-employee co-insurance — all at the rules engine, applied consistently across every episode and every patient. The patient invoice carries the breakdown the regulator and the patient expect. Electronic invoice emission with real-time validation status.
Multi-entity group view
Group revenue consolidated across all entities. Inter-entity patient transfers — admitted at one hospital, discharged at another — reconciled across the group ledger. Revenue-per-DRG, case-mix index and denial rate comparable across the network. The group CFO's question answered as a query. Automatic synchronisation to Axional ERP: every issued invoice lands as an accounts-receivable entry, starts the accounting circuit and is followed through to collection — zero dual entry between clinical billing and the financial back-office.
Why the revenue cycle has to be in the engine.
The complexity of hospital revenue is not in the grouper algorithm. The DRG grouper is largely a published specification — available to any vendor willing to implement it. The complexity is in the rules around it: what counts as one episode versus two, when a clinical decision is administratively reimbursable, which payer adjudicates first in a multi-cover scenario, how state-employee co-insurance overlays on private coverage, when a denial is appealable and when it is final. Each of these is a rule that changes per payer, per market, per regulation cycle. Implementing them as middleware produces thousands of lines of custom code per customer and a reconciliation process that breaks when any rule changes.
In Axional Health Suite, every one of these rules is a row in the metadata repository — parameterised, version-controlled, auditable. The team that updates the rules when a Spanish autonomous community changes a coverage threshold, or when EsSalud Peru revises the SITEDS validation protocol, is the same team that wrote the engine. The hospital does not wait for a middleware patch, and does not retain a specialist integrator to maintain the connection. When the rule changes, the billing cycle reflects it on the next admission.
Hospital Angloamericano in Peru runs Axional Health Suite alongside SAP for corporate finance and TrakCare for clinical management. The architecture demonstrates coexistence, not displacement: the revenue cycle module connects to the clinical system upstream via HL7, receives the episode data it needs to group and bill, and synchronises downstream to the ERP for accounts-receivable accounting. The integration surface is the engine's standard interface — not a bespoke bridge built for that customer.