Sumex Suite
Flexible and automated claims processing for the Swiss healthcare system
The Sumex Suite is a flexible workflow solution for automated processing of claims documents in the Swiss healthcare system. It ensures efficient checks, integrated expertise, and a high degree of automation, reducing transaction costs to a minimum.
Utilizing advanced technologies, Sumex Suite streamlines the verification and validation of claims, integrates seamlessly with existing systems, and provides customizable dashboards for comprehensive oversight. With features like real-time data analysis, automated workflows, proactive fraud detection, and compliance monitoring, Sumex Suite optimizes resource allocation and enhances service quality in claims management.
Claims Processing
Claims Processing at Sumex ensures efficient checks, integrated expertise, and a high degree of automation, reducing transaction costs to a minimum. Utilizing advanced technologies, our solutions streamline the verification and validation of claims, integrating seamlessly with existing systems.
Our automated workflows and real-time data analysis enhance accuracy and speed, while customizable dashboards provide comprehensive oversight. With proactive fraud detection and compliance monitoring, Sumex ensures that claims are processed swiftly and accurately, optimizing resource allocation and improving overall service quality.
Sumex Core
Sumex Core is the basis for automated electronic invoice verification. It contains the business components and workflows, which can be assembled and parameterized in a modular way.
Reference Data
Centralized Tariff and Data Management for Accurate Billing
Current and correct tariff and reference data are central to efficient invoice verification. Sumex reference data is compiled from publicly available sources, processed in a timely manner and made available on the Sumex tariff server. The data is additionally presented in an information system and can be consulted directly by the experts in the context of the current billing.
- TARMED tariff and structure incl. general information (GI) and PIK decisions
- GTIN drug master database with over 320'000 articles incl. MiGeL linkage, Swissmedic - specialist as well as patient information, compendium, list of specialties (SL), WHO active substance information and more.
- Over 90 additional ambulatory and hospital rates (e.g. Federal Analysis List EAL, Medium and Item List MiGeL, amongst others)
- Baserates for the UV / MV / IV sector
- Tariff agreements
- Partner base
Sumex Expert Systems digitally support the analysis and validation of billed services, presenting relevant rules for validated invoices.
Expert Systems
Analytics
Sumex Analytics optimizes controlling and supports experts via statistical data and analytical models.
Platform
The Analytics Platform can check the plausibility of invoices and uses a variety of methods from probability theory, statistics and machine learning. The models on which the checks are based are trained using a large amount of existing invoice data and refined with the help of technical experts. In addition, Sumex customers can use their own models to customize the billing process.
Box
The Box is a tool for automatic checking of SwissDRG invoices and Minimal Clinical Datasets (MCDs) in batch processing. It comprises a series of checks that draw on various sources of information: billing statistics, data from the fee-per-case catalog, grouping results, and information derived analytically from SwissDRG regulations. If the check identifies anomalies, the corresponding invoices are set aside and notes are placed in the expert systems to enable efficient manual processing.
Capturing
Automated Optimized Service Entry allows scanned medical bills to be digitized for review in Sumex.
Optimised service capture
The Sumex Suite automatically and optimally digitizes invoices. During digitization, the invoices submitted on paper are automatically supplemented with insured person data, case data and information on the ordering party, service provider and invoicing party from the data master of the connected partner systems. Thanks to comprehensive integration with the Sumex Suite, and other core or peripheral systems, with just a few entries any user can efficiently edit or supplement data that could not be digitized correctly or completely.
Mobile
The Mobile Capturing modules enable high-quality capturing of invoices via a mobile device. This includes image recognition, precise cropping and intuitive user guidance to ensure quality.
In addition, the data is extracted from the image and is available as JSON or XML for seamless further processing.
Medical Invoice Translation
Today's medical bills are confusingly structured and full of incomprehensible jargon. Insurance companies have to explain the bill to their policyholders. But even then, it is still very difficult for the insured to understand what exactly was billed. With the Medical Invoice Translation module, the Sumex Suite offers the possibility to resolve the technical jargon issue and present an easily understandable medical invoice to patients.
Understandable medical bill
The service provides a simple interface for translating medical services into descriptions that can be understood by laypersons. The vocabulary was developed together with the Department of Applied Linguistics at the ZHAW. Continuous additions to the vocabulary ensure that the latest rate changes are also translated correctly.
The service processes various formats, such as the XML format of the Forum data exchange for the general invoice, thus allowing easy integration into existing systems. The result of the translation can be output as PDF, JSON or again in XML format.