The Sumex Suite is a flexible workflow solution for automated processing of claims documents in the Swiss healthcare system.

Claims Processing

Efficient checks, integrated expertise and a high degree of automation reduce the transaction costs of vouchers to a minimum.

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.

 

 

 

 

 

 

 

Claims Processing Sumex

 

Sumex Referenzdaten

Reference Data

Sumex Referenzdaten

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 170'000 articles incl. MiGeL linkage, Swissmedic - specialist as well as patient information, compendium, list of specialties (SL), WHO active substance information, ...

  • Over 80 additional ambulatory  and hospital rates (e.g. Federal Analysis List EAL, Medium and Item List MiGeL, etc.)

  • Baserates for the UV / MV / IV sector

  • Tariff agreements

  • Partner base

Expert Systems

Sumex Expert Systems support the analysis and validation of services billed according to inpatient tariff structures. The systems present, in digital form, the rules and regulations pertaining to invoices that have been validated. 

DRG Expert

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DRG Expert supports the controlling of billing for services in acute care, created according to SwissDRG regulations. DRG Expert presents case data in the context of regulations, contains statistical key figures and offers what-if analyses. Other functionalities include a medical thesaurus, references to coding guidelines and real-time grouping with the SwissDRG Grouper. 

  

The experts can enter notes in the ICD and CHOP catalogue. These notes can be private or shared with other staff. The notes are automatically migrated to the latest tariff versions. 

  

DRG Expert is integrated with Sumex Core, but can also be integrated with other systems or used standalone. 

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Sumex Tarpsy Expert

TARPSY Expert

Sumex Tarpsy Expert

TARPSY Expert provides support for controlling psychiatric services billing created according to the TARPSY rules. The TARPSY Expert is based on the DRG Expert and provides the same proven functions adapted to the TARPSY framework. 

REHA Expert

Sumex REHA Expert

Support for controlling the billing of rehabilitation services created according to ST Reha rules. REHA Expert is based on DRG Expert and provides the same proven functions adapted to the ST Reha framework. 

 

Sumex REHA Expert

Analytics

Sumex Analytics optimizes controlling and supports experts via statistical data and analytical models. 

Platform

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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. 

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Sumex Box

Box

Sumex 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

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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.

 

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Sumex Mobile Capturing

Mobile

Sumex Mobile Capturing

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

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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.

 

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