Tuality Health Alliance Leverages Integrated Suite of Automated Solutions

Client SpotlightTuality Health Alliance (Tuality) is a physician-hospital community organization that contracts with over a dozen health plans. Their physician membership includes approximately 80 primary-care physicians and 200 specialists. Tuality went live with SymKey® for Plexis Claims Manager™ in mid-July, 2014. Within the first month, they were processing an average of 400 claims per hour with SymKey®. Tuality also licensed Virtual Examiner® and Virtual Auto-Post this past October and has been realizing incredible cost and time savings from both solutions.

The SymKey® Experience

Using SymKey® for Professional and Hospital claims, as well as Virtual Auto-Post, Tuality has been experiencing automated processing speeds that are about 8x faster than manual. They have also been running scheduled SymKey® claims batches at 2 a.m. every morning, seven days per week, resulting in even greater efficiencies.

“SymKey® has taken our very tedious and quite repetitive manual work and practically eliminated it! We now have time to actually focus on accuracy and proper payment, rather than just data entry. We are becoming true claim examiners,” said Julie Spiert, Operations Manager at Tuality Health Alliance.

This automation has allowed Tuality to complete their claims quickly and more accurately, with a 25% reduction in claims staff. Their highest-impact workflow scenarios are:

  • NDC Removal – For their Medicaid plan, SymKey® reduced state pends from 200+ per month down to 9 by removing NDCs from procedure codes that do not require it.
  • Claim Mirror – SymKey® takes an already processed claim and re-enters it for us
  • Non-Matched Tax ID – SymKey® pends EDI claims from Providers with multiple accounts so examiners can select the proper account to submit payment to.
  • Custom EOB Creation – A particular charity LOB requires creative EOBs for their members, so after adjudication SymKey® moves all write off amounts to the ineligible field, removes all EOB codes, then adds one EOB code that identifies the charity.

Spiert went on to elaborate, “It is common for us to have large reprocessing projects due to a variety of reasons that are beyond our control. SymKey’s ability to re-enter a claim has cut the amount of time those projects take in half! Our check run closing process has also been favorably impacted by having SymKey® doing the work of running through various error reports and correcting claims, as opposed to us having to do it manually! WE LOVE IT!”

Their Advice?

“Try and trust. Think outside the box! Understand that SymKey® is another examiner, so anything that you can do, SymKey® can do it faster with accuracy 100% of the time!”

The Virtual Examiner® Experience

Tuality also began retaining premium dollars with Virtual Examiner® (VE), which reviews their claims for fraud and abuse using over 31 million claim edits per line to identify unclean claims and reduce payment for improper or erroneous coding. VE was seamlessly integrated with PCM and the process of applying CCI edits was automated with SymKey® Virtual Auto-Post.

“There was an absurd amount of dollars that we were paying out prior to VE. We hope to see a savings of roughly $60k per month as we continue to add queries and further utilize Virtual Auto-Post. It currently saves us around 8 hours per week just for the CCI edits; I can’t wait to see how much time it will save once we turn on the rest of the edits!” said Spiert.

Customer Service

“The HCIM staff has been awesome to work with since day one! We really threw some new and interesting challenges at the HCIM staff and they have worked through every complex workflow scenario with us to find automation solutions. Everyone is extremely helpful, quick to respond and readily available to answer all of our questions/concerns. We can’t say enough good things about SymKey®, Virtual Examiner® and HCIM customer support! Our only regret is that we didn’t hear about you years ago!” said Chris Senz, COO of Tuality.

About HCIM

Since 2000, HealthCare Information Management, Inc. (HCIM) has delivered expert consulting services and robotic automation tools for small to mid-sized healthcare payer and managed care organizations. Our concierge consulting services include everything from core claims system procurement to go live, including configuration, migration, upgrades, reporting, benefits and fee schedules, user training, and project resourcing. We also offer strategic consulting in the areas of value based payments, population health, medical management, medical loss analysis and recovery, care management, provider contract modeling, data analytics, and business process reengineering/analysis.