SUTTER HEALTH & TRIZETTO PROVIDER SOLUTIONS

THE CLIENT

Sutter Health, a not-for-profit headquartered in Sacramento, operates over 200 hospitals and clinics in Northern California.

THE CHALLENGE

Sutter Health was looking for a solution to help them recover revenue from underpaid provider claims.

The organization lacked a solution that easily identified payers that were not reimbursing claims properly and consistently. They were in need of a way to reconcile actual provider payments against expected reimbursement from the contract. To add to their dilemma, they did not have a way to manage their provider contracts, as only hospital contracts were loaded in their practice management system. Money was being left on the table, but without resources and the proper systems and workflows in place, their hands were tied.

THE SOLUTION

Advanced Reimbursement Manager (ARM) from TPS was implemented to help Sutter Health easily monitor transactions and identify underpayments, along with its ability to swiftly remedy claims to regain revenue. The tool was also chosen to manage physician contracts efficiently. Additionally, the organization uses ARM to report payments, request contract recovery detail reports, and document payments and balances.

THE OUTCOME

Since implementing the ARM tool in 2012, Sutter Health reports that an estimated $30-40 million in revenue has been captured. On average, that amounts to approximately $4 million annually in collections over the course of the last ten years that would have otherwise been lost revenue. ARM enabled Sutter Health to identify and recover $6.7 million in denied claims by utilizing our automated appeals to rework 25,000 claims. This constitutes a realized 66:1 return on investment when comparing the cost of the tool and the revenue recovered.

As a long-term user of the ARM tool, the organization cites the clean display of non-convoluted data as one of the main benefits, along with the ability to request and send detailed reports. Its automation is also much appreciated, since it helps eliminate the need for manual inspection of individual payments, freeing up valuable time. Users at Sutter Health share that the ARM functionality from TPS holds more benefits than similar options on the market due to its advanced edits and payer rules. Sutter Health continues to utilize the ARM tool to gain advanced reporting and ensure optimal revenue capture.