For those in healthcare. By those in healthcare.

Automating the claims adjudication process to strengthen provider relationships

Tuality Health Alliance is a physician-hospital community organization (PHCO) that includes approximately 80 primary-care physicians and 200 specialists. Based in Hillsboro-Ore, Tuality represents the interests of patients, physicians and other care providers with many national and regional insurers and health plans, and is responsible for effective medical management and quality improvement services. They are also the plan administrator for Tuality Hospital’s medical plan.

Because of the small size of the administrative staff, Tuality’s Chief Operating Officer Chris Senz and Operations, Data and Reporting Manager Julie Spiert were eager to uncover new ways to automate the various manual processes Tuality currently had in place. Because of the industry’s rapid transformation over the past few years, there was also the need to contain costs to remain competitive, while protecting themselves from becoming yet another headline related to the billions of dollars lost each year to fraudulent, abusive and wasteful healthcare billing practices.

After a thorough review of vendor alternatives, Senz and Spiert reached out to the Las Vegas-based PCG Software for an evaluation of the organization’s existing claims operations in 2014. The consultants at PCG Software ran a comprehensive review of all Tuality claims data from 2012, and returned with some eye-opening results. After running the already-paid claims data through its flagship software platform, Virtual Examiner (VE), PCG Software identified dozens upon dozens of instances where Tuality should have rejected submitted claims, or in many cases, should have paid a lesser amount. The bottom line? PCG Software identified a cost savings opportunity of nearly 10 percent for that year – equating to hundreds of thousands of dollars Tuality could have saved, if the system was in place at the time. It was a convincing argument.

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claims adjudication, PCG Software, Tuality Health Alliance, Virtual Examiner


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