| AMRHEALTH's - AVS Reimbursement System |
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ADVANCED VALUE SCALE (AVS) REIMBURSEMENT SYSTEM AMRHEALTH'S Advanced Value Scale (AVS) is system developed as a cost containment tool for use within the health care reimbursement process. This tool integrates clinical expertise, rules, and policies compliant with industry standard reimbursement methodology to price claims, identify physicians claim coding errors and manage valuable health care information to fight fraud and abuse. It automates a knowledge base of medical protocol for editing on both a prospective and retrospective basis to produce significant hard-dollar savings through the elimination of payments for miscoded and mispriced claims. These powerful knowledge-based processes can be run stand-alone or integrated with claims pricing, claims payment, and claims review systems. The data is captured, cleansed, and warehoused to deliver valuable information for improving a health plan's performance. AMR's Advanced Value Scale is unique because it uses responsible and reliable reimbursement methodologies. AVS is the only system that provides full integration of clinical edits with pricing and measurement based on the RBRVS (Resource Based Relative Value Scale) and NCCI. AVS is the perfect yardstick not only for pricing claims but also for measuring provider performance and provides powerful information to monitor and improve health plan cost-containment strategies. The AMR-Advanced Value Scale System is available for IBM's AS/400 Advanced Series platform. The system is complete and includes all of the necessary data bases, rule sets, and software. It is highly tailorable and can be easily customized to work with a variety of claim pricing and adjudication processing environments. CODING STANDARDS AVS is a responsible and defensible series of processes that have translated clinical coding policies and rules into highly intelligent knowledge-based processes. The policies are based on medical/ surgical practice standards and guidelines and CPT(R) coding standards. CPT is a registered trademark of the American Medical Association. The policies used by AVS are based on the National Correct Coding Initiative (NCCI). The NCCI policy was developed by the Health Care Financing Administration and is the published national coding standards. These policies incorporate published guidelines and protocols with input from the AMA, American College of Physicians, Journal of American Medical Association, Federal Register, The American College of Cardiologists, and numerous practice specialty organizations. The coding is based on the AMA's CPT(R) coding nomenclature, ICD-9, HCPCS, and HCFA's standard codes for place of service, type of service, and specialty. CLINICAL LOGIC The AMR-AVS is comprised of over 115+ edits that involve millions of procedure code combinations used in conjunction with the standard edit codes identified within the National Correct Coding Initiative. The system builds powerful knowledge bases that can be easily accessed and tailored for a specific code or group of codes for each specific edit. The clinical logic can be easily tailored to the specific payment provisions of a health plan. The coding guidelines can be tailored by specialty within specific groups or plans. CUSTOMIZATION The systems architecture allows for every component of the system to be customized. The customization allows the user to set switches within each coding edit for inclusion or exclusion. The system also allows for alteration of CPT(R) code range within the edit processes. Global fee periods and specific code combinations can be easily changed to suit a particular environment. The system supports Medicare, Medicaid as well as commercial lines of business. INTEGRATION A complete integration interface is provided that allows the user to control the claim disposition when the edit result is passed to the claims adjudication process. The pricing component is fully integrated with the edit process. The system not only flags but also prices, adjusts the prices, passes control values to the claims process, and produces the appropriate policy language to defend the edit. The claim control values can be used to pend, deny, and produce ineligible codes for messages printed on the claim systems E.O.B.'s. PRIVATE PRICING The system provides extensive pricing capabilities including fee schedule, case rate, per diem and percentage of discount to accommodate commercial and government assisted programs. The pricing component includes RBRVS and can price Medicare, Medicaid, Workers Compensation, and shared risk arrangements. Within the private component, pricing can be developed for preferred arrangements as well as for replacing the prevailing charge-based system. Special pricing can be established for networks, providers within networks in combination with geography, specialty, and CPT(R) code range. Virtually any combination of pricing arrangements can be established. EDITS A complete series of clinical edits are included: (over 115) Pricing/Code Status Injections (J-codes) Modifier Global Surgery Site of Service Multiple Surgery PC/TC Bilateral Surgery Unbundle (12 individual types) Assist at Surgery Mutually Exclusive (2 individual edit types) Co-Surgeons Global ZZZ Team Surgery Billable Medical Supplies DME (Durable Medical Equipment) ICD-9 to CPT(R) LAB ICD-9 specificity Requires documentation edits SMART SOFTWARE BUILT AROUND KNOWLEDGE Everything you need is included to start pricing, editing, and managing physician bills immediately. It is complete with a master physician fee schedule, zip code cross reference, geographic practice cost indexes, relative values, modifiers, edit tables, and conversion factors. It also includes CPT(R) codes and HCPCS. Everything including policy manuals and coding rules that back up your coding decisions. All of the data is date sensitive and updated by AMRhealth on an ongoing basis. CARE MANAGEMENT & ANALYSIS AVS allows you to develop a sophisticated data repository of claims experience that enables you to measure and analyze the performance of your cost-containment initiatives. The process will help you to develop and evaluate fee schedules based on RBRVS. You can use the data to measure provider performance and evaluate your health plan cost-containment strategies. DESIGN FEATURES Batch and Interactive Entry Proven Value-Scale Pricing Windows-Based Multi-Line Claims Entry OLE Compliant Prints Pricing Tables Individual Pricing Sheets Conforms to CCI Obsoletes UCR Individual Provider Overrides Includes Complete Fee Schedule (CPT(R) and HCPCS) Medicare Capability Supports Preferred Pricing Optional Clinical Lab Schedules Optional DME J-Code Fees BUILT IN KNOWLEDGE BASIS AVS includes all the necessary knowledge basis which can be tailored to your unique coding guidelines. All data is date specific which allows you to price and edit by date of service. These include: - RBRVS values and edits within Medicare Physician Fee Schedule - Complete Zip Code Table with Medicare Carrier Locality Mapping - Geographic Adjustment Features - Unbundling and Mutually Exclusive Code Sets - E & M Allowed - Surgical Episode Tracking - LAB Fee Schedule - DME Fee Schedule - J-Code Fee Schedule - ICD-9 to CPT(R) - ICD Level of Specificity - Codes/Modifiers/ICD-9 requiring documentation SUPPORT AMR builds strategic partnerships to help our clients make better reimbursement decisions. Complete systems are licensed on an annual basis; multi-year arrangements are available. Data is updated every three months. The annual fee provides program error correction service and toll-free help desk. Optional clinical support services are available that provides edit and policy interpretation in support of the claim-edit processes. SYSTEM REQUIREMENTS
LICENSE USE AND PROTECTION OF PROPRIETARY INFORMATION The information contained in AVS is proprietary to AMRhealth and its suppliers and is intended for use by licensed users only. OWNERSHIP The Licensed Software and Documentation and the copyrights, patent rights, trade secrets, trademarks, and other intellectual property in or to the Licensed Software and/or Documentation are the exclusive property of AMRhealth and its licensors. Notwithstanding anything in this Agreement to the contrary, AMRhealth and its licensors retain title to the Licensed Software and Documentation. Copies of the Licensed Software and Documentation are provided on a usage basis to Client to facilitate the exercise of rights under the License for the term of the License.
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