CASE STUDY
SunStone Consulting
Healthcare Process Automation
Client Background
SunStone Consulting is a company that specializes in simplifying the intricate process of billing and collection
for hospitals, especially in dealing with complex regulations and coding systems. They possess in-depth expertise in reimbursement and regulatory principles, covering MS-DRG’s, HCPCS, CPT coding guidelines, ICD-9-CM, and ICD-10-CM coding, as well as charging processes and clinical operations.
Leveraging extensive experience in documentation, coding, billing, and compliance initiatives, combined with industry knowledge, SunStone provides comprehensive and effective solutions surpassing other healthcare consultants. Their services cater to healthcare providers of all sizes, from large hospital groups to professional physician groups, and extend to specialized areas such as FQHC, RHC, transplant hospitals, and clinical research services.
The Challenge
Diverse regulations and reimbursement policies across states pose a growing challenge for hospitals dealing with Medicare and Medicaid claims reimbursement, leading to underfunded claims and revenue leakage. Compounding this complexity is the disparate nature of data sources delivering these rules and regulations.
SunStone needed a fully automated business process to respond to this challenge by introducing revenue integrity services aimed at optimizing hospital reimbursement from both Medicare and Medicaid claims. Leveraging their extensive experience in documentation, coding, billing, and compliance initiatives, coupled with a comprehensive understanding of reimbursement principles.
The Solution
Collective Intelligence designed a consulting process to address the challenges hospitals face in validating Medicare and Medicaid claims reimbursement due to diverse state regulations and reimbursement policies. The offering includes policy tracking, claim level validation, billing calculations, and reconciliation with state-level Medicaid reimbursements. It also provides detailed reporting of outlier claims.
The solution integrates with the customer’s expertise in reimbursement principles, documentation, coding, billing, and compliance initiatives to optimize revenue integrity for hospitals of all sizes and specializations.
Project Outcome
SunStone Consulting and Collective Intelligence developed a solution to address the complexities of Medicare and Medicaid reimbursement by aggregating datasets from various states, calculating expected and actual reimbursement for hospitals, and providing insight into underpaid and miscalculated claims.
The solution uses a modern Lakehouse architecture, Power BI tools, and enforces stringent business rules to ensure accuracy and compliance. This approach provides actionable intelligence for informed decision-making using advanced, self-service analytics.
Hospitals now have a tool to guarantee that they are accurately reimbursed for Medicaid services delivered. Reports provided to hospitals give them the information they need to retool business processes, adjust claims, coding procedures, and identify potential outlier encounters, saving hospitals hundreds of thousands of dollars annually.
PROJECT DELIVERABLES
- Product definition and product design
- Deployment and configuration of the Databricks data intelligence platform
- Cloud architecture services aimed at the client’s Azure tenant
- Data engineering covering data ingestion, business rule implementation and ELT processes using Apache Spark.
- Creation of an advanced Data Lakehouse
- Creation of self service, business analytics workspaces utilizing the Data Lakehouse as a multidimensional data source accessible via Microsoft Power BI
- End-to-end support extended to ongoing maintenance, covering both the application and the underlying infrastructure, ensuring the continued success of the implemented solution
The Impact
- Automated data discovery and processing
- Huge time savings for the team
- Informed business decision making
- Process handling for multiple customer types
- Saved the client’s customers hundreds of thousands of dollars
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