AMRHEALTH    -   CCARS
Cost Containment Audit Recovery Services

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Cost Containment, Audit and Review Service (CCARS) provides a complete retrospective analysis and compliance audit for a group or batch of claims, which have been previously processed and typically identifies 5% of incorrectly processed claims for recovery. This service is non-invasive and does not require any changes to current operations, infrastructure, equipment or software.

The claim batches can be from any external claims payment source and can arrive in any format. Utilizing AMRHEALTH’s Advanced Value Scale (AVS) tool set the claims data is mapped, each claim line processed against over 130 coding and compliance rules and detailed reports are then available for Plan Administrator or auditor to use in refining the current plan, recovery, or future negotiations. These rules identify both overpayments from of provider coding errors and/or payor payment processing errors.

Good Question, but the process of correct coding and correct reimbursement is complex and involves the validation of tens of thousands of coding combinations. Most claims payment system now in use do not review or adjust claims for every possible coding combination or condition. Most, do not have the capability for integrating correct coding compliance within the plan business rules. Perhaps contributing to why there is roughly 100 billion of Health Care fraud and abuse occurring annually.

The CCARS compliance process provides a valuable and cost effective program for payors and health plans to improve their payment processes and decrease potential compliance problems with Medicare, Medicaid and commercial health plans.

• Identifies inappropriate coding
• Identifies overpayments
• Helps to spot billing errors
• Recover lost dollars
• Reduce claims expenses
• Improve payment effectiveness

AVS - Advanced Value Scale is a fully integrated code management system with over 130 compliance audits. AVS is a methodology that represents the next generation of healthcare reimbursement. It dynamically determines the price of a claim based on the rules and policies of correct coding. AVS dynamically creates a price for each procedure or service performed based on all of the related treatment factors, including past history, other claim line combinations, geographic location, site of service, specific network and provider contract etc. Procedures are not only priced and then edited for correct coding and adjusted accordingly. It even includes a proprietary tracking mechanism to test for duplicate submission and for conformance to global surgical packaging.

The pricing and coding methodologies utilized by AVS are fully defensible since they have been developed in accordance with methodologies recommended by the National Correct Coding Initiatives(NCCI), the Centers for Medicare & Medicaid Services' Bureau of Program Operations(BPO) and the RBRVS Update Committee(RUC). They follow Medicare guidelines and can be adapted to specific physician specialties. The coding edits included are designed to control improper coding that leads to inappropriate increased reimbursement in physical claims.

The coding conventions and policies developed closely conform to those defined in the American Medical Association’s(AMA) CPT(R) Manual, in national and local policies and edits, in coding guidelines developed by national societies, in analysis of standard medical and surgical practice, and in review of current coding practices.

CPT is a registered trademark of the American Medical Association.

The CCARS service can be performed off site with information sent to sponsor, conducted on site or accessed through secured Internet pathways for real-time analysis during field investigation. AVS can identify areas of abuse and provide for specific identification of claim problems. However performed Plan Administrator can drill deep into the claims history and find the real problems. Once a claim error is identified, users can drill down to specific claims and generate a detailed claims audit report for a specified encounter, episode of care or claim.

Following is a typical example of how the AVS toolset conducts an Audit. Shown are some of the on-line options and reports that can be used for auditing health plans. The following menu represents only one small aspect of the powerful CCAARS/AVS Audit process capabilities.

Sample Health Plan 17:25:03

1. Create Client Claim Data From Client Raw Data

2. Run AVS Against Client Claim Data

3. Create Client Summary Work File

4. Update Client Claim Data With AVS U&C

5. AVS Statistics Summary Report (1 Pg Bal Report)

6. Client Claim Inquiry By Audit Code (With Auditors Report Option)

7. Audit Category Summary Report (By Severity)

8. Savings Opportunity Exception Report (By Audit Code & Severity)

9. Detailed Audit Flag Exception Report (By Severity)

10. AVS Demand Audit Report (By Claim # Or Member ID)

11. AVS Procedure Summary Report: All Procedures

12. Claim Auditors Report (By SSN)

Once claims information has been received and processed a complete series of summary and detail reports are now available which provide powerful tools to quickly and easily pinpoint coding problems and overpayments. When used in conjunction with follow-on site review and investigative services, they represent a powerful offering that can reduce claims payment errors and improve the effectiveness of the health plan. Rember these are just some basic examples additional reports and analysis can be customized for any needs.

This step reads the clients raw data and creates a claim detail file on our host computer system. Data provided can be on CD or Diskette and in ASCII, CSV, TAB or even Excel or Access files. A year worth of claims data is suggested but we can do shorter runs too. This normalized database containing the claim history will be electronically scanned against the AVS knowledgebase. Once claims data is provided no other actions are required on part of client. All processing will occur at AMRHEALTH’s Network Operations Center.

Data is formatted and client claims detail file is created for processing by the AVS compliance engine. AVS logs and history records are created during this process, which become the basis for electronic analysis shown below. It is also available to the auditor for detailed analysis.

Using clients reformatted data (from step 2), data is now processed and the AVS Detailed Audit Flag Report is created, a detailed claim line report within AVS audit flag type. This reports contains all claims/line detail and is seldom printed because of its size. It is used as an electronic repository for specific claims information identified in subsequent benchmarks.

Summary Report provides specific totals for each of the audit category flags and individual AVS edit flags. It provides claim number, member ID, provider ID, CPT(R) code, submitted amount, reduced amount, allowed amount and actual payment amount.

Establishes a pricing benchmark against the actual allowances by the payor. This benchmark enables the auditor to identify pricing outliers for both in and out of network claims.

AVS Audit Analysis Of Historical Claims report is a snapshot of total claims audited for the period submitted and what audits were found and performed. Creating a 1 page total summary report listing totals for claim lines, Submitted, Reduced, and Allowed Amounts, Total Number Of Audits Triggered, Total Amount Audited, Number Of Audit Reduction, and Total Of Audit Reduction. Provides a quick thumbnail sketch of Audit

Provides an on-line query function for access to any claim within any audit trigger. Allows the auditor to easily identify claim errors and drill down to a specific error. Once identified, the auditor can request a detailed audit report that assembles all of the claim information in an easy to use format.

Using AVS summary work file as input and creates the AVS Audit Summary By Type adn Category, a 3 page summary report by audit code listing Audit Count, Submitted, Reduced, Allow, Paid, and Paid Vs Allowed Amounts. A summary line is printed for every audit type and is used to identify the total savings opportunity available for each of the AVS 130 compliance audit triggers.

Again using AVS history log as input the AVS Detailed Audit Flag Exception Report is created, an exception report of AVS audit codes in instances where the paid amount is in excess of the allowed amount. Listing Submitted, Reduced, Allowed , and Paid Amounts it identifies the specific savings opportunity and provides an efficient tool to identify those large dollar abuse situations and specific recovery opportunities.

Similar to 8, enables retrieval of problem claims based on the severity levels.

10, Drill Down, Problem Claim Report (AVS Demand Audit Report);

Once a claim is identified, detail and history can be produced to aide investigation and resolution. AVS Claim Auditors Report uses the client claim file as input and creates a detailed analysis and report of a specific claim. It provides all necessary information to evaluate and analyze a specific claim for billing and payment issues. It identifies all AVS audit triggers and calculates appropriate payment allowances based on the AVS audit process. Reports can be created by claim or for all claims for an individual member.

Using the client claim file as input the Procedure Summary Report summarizes each claim line by procedure code. Used to identify high value and high usage procedures. It prints CPT(R) code, total quantity, Submitted Amount total, the average submitted amount, total allowed amount, and the allowance average.

12, High Value Drill Down by Member (Client Claims By SSN And Claim Number);

The AVS Claim by Member Report identifies each claim line by the specific member ID. This report has the option to print either one summarized line (summary) for all of a members claims or individual lines (detailed) for each claim. It provides a means to identify by member, high dollar abuse situations.

Detailed Audit Flag Report

This report provides the means to identify all of the claim abuse by a particular audit trigger. You can use this report to identify the high dollar abuse situations while focusing on a particular audit issue. Since this report can be quite lengthy depending on the volume of claims in the batch, the Audit Summary is used to identify the areas of abuse. Sections of this report can be selected for printing as the user focuses on a particular audit flag type.

 

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