Tri-City Medical Center (TCMC) is a 397-bed, full service acute-care medical center in southern California, serving residents of north San Diego County since 1961. A 15-year client of MedAssets, TCMC received a three-year JCAHO Accreditation in 2003 and has been designated as a 100 Top Hospital on three separate occasions by HCIA/Mercer.

TCMC implemented a managed care audit program using Crystal Reports, one of Alliance Decision Support®’s robust reporting tools. These reports identify variances between actual and expected payment terms and the details supporting expected payment calculations. The discrepancies identified are shared during contract negotiations with the expectation that unpaid/underpaid accounts be paid as a condition of the contract renewal. Discrepancies include but are not limited to underpayments, denials, difference of interpretation of a reimbursement term, etc. Over the last two years, TCMC has recovered $4 million additional dollars using this spreadsheet collection method.

When auditing, the data can be sorted in a variety of ways (by paid amount, service type, insurance code, etc.) to track and trend the information. To assist in the accuracy of accounts receivable, TCMC processes data daily through Alliance. Using the system’s batch-loading processes to calculate and create file extracts for contractuals, they are able to post these contractuals to accounts receivable at the time of billing.

This provides patient accounting with a more accurate picture of receivables and helps the organization better manage cash flow.

TCMC has effectively operationalized the information from Alliance not only for the managed care staff for auditing purposes, but also for the Business Office by producing routine credit balance reports for action, and dashboard reports for the management team with tracking and trending information by payor.

According to Kerry Mills, director of managed care, “Knowledge is power. Armed with the data we extract from the Alliance Decision Support system, TCMC has the ammunition to effectively challenge the delay, defer, denial tactics which are so common amongst payors today. We are actively working to further automate the process with the help of our partners at MedAssets.”