AWAC.MD

AWAC® has designed a physician-based approach to identifying expensive cases early and managing them in a way that ensures quality care at the best possible pricing.

Situation

Self insured employer groups, third party administrators, managing general underwriters and carriers know that the greatest impact on a health plan’s costs comes from large individual claims. It is critical to not only identify these cases early, before they escalate into catastrophic claims, but also to have the intervention tools to provide effective medical and financial management to ensure quality care, avoid variances and contain costs.

Yet most plans simply don’t have the expertise to identify cases early, recognize fraud, abuse or errors in complicated medical billing or to effectively negotiate with providers. It takes a skilled physician, with hands-on experience in the specialty in question, to communicate with attending physicians, manage expensive cases, review billing in a clinical context and negotiate claims.

Solutions

AWAC® is a physician-based technology-enhanced longitudinal approach to identifying expensive and problem cases early and managing them in a way that ensures quality care at the best possible pricing. Better than predictive modeling, AWAC® not only finds the problems, its team fixes the problems. The company offers comprehensive, nationwide medical management services that are not limited by diagnosis or problem, including:

• Early identification of catastrophic cases (clinically or financially)
• A la carte medical management services
• A national provider network
• Specialty multidisciplinary care managers
• Pre-admission negotiations
• Physician claims review and retroactive negotiations
• A disease management program for:
  • transplant
  • liver
  • cardiology
  • orthopedic
  • oncology
  • neonatal injectables and specialty medication
    •  A comprehensive wellness program
    • A URAC – accredited Precertification and Utilization Service Program

Step 1 - Electronic Surveillance and Early Identification: The process begins with the company’s Advanced Warning and Containment® (AWAC®) software. Built around a database of more than 60,000 physician-produced algorithms, tens of thousands of actual cases, and millions of claims, the program is the first and only electronic claims surveillance system of its kind in existence. It securely downloads and scans clients’ claims data, prescriptions and pre-certification records every night. By comparing these to information in more than 50 separate databases, the program identifies cases that are likely to become catastrophic, sometimes from a claim as small as $30. It also infers outcomes and recommends possible actions. AWAC® physicians then review the cases the program identifies and do custom reviews based on their knowledge of insureds or providers. This all happens daily, before the claims are paid.

Step 2 - Medical Management: The key to AWAC®’s success is a dedicated team of board certified physicians who monitor the data and serve as on-call medical directors, managing the cases AWAC® identifies. These physicians are supported by registered nurses, certified case managers, home infusion therapists, pharmacists, pharmacotherapists, health care administrators, quality assurance experts, utilization review professionals, coding experts, specialty case managers, dieticians, social workers and more than one hundred physician specialists. Once AWAC® identifies a case, an AWAC® physician and other team members work with the client, patient and attending physician to ensure the best possible care at optimum savings.

AWAC® physicians and consulting specialists also review billing to provide clinical correlation, make sure the procedures were done and are coded correctly and then to make sure prices are based on the true costs of care delivered – something they know first-hand. If they identify questionable items, they discuss and negotiate physician to physician.

Step 3 - An Extensive Provider Network that Offers Real Discounts: AWAC® clients can also take advantage of the company’s comprehensive, nationwide provider network, without paying PEPM access fees. Unlike PPOs, where prices may be inflated then discounted back to normal, IHS contract prices are negotiated on a true-cost basis. So AWAC® clients enjoy significant cost reductions in areas such as cancer treatment, pharmaceuticals, injectables, kidney disease and dialysis, liver disease, organ transplants, neonatology, diabetes management and many others.

Step 4 - Medical Precertification and Utilization Review: AWAC® offers a physician-led, URAC – accredited precertification and utilization service with iProcertPLUS™, totally integrating utilization management into the AWAC® system of cost reduction and disease management options.

iProcert™ systems are electronically interfaced to AWAC® to assure accurate and timely transmission of appropriate and necessary data. AWAC® physicians review this data for clinical or financial indicators that would predict the need for case management, early discharge planning, long term care needs (as in patient or out patient), disease management requirements or potential cost containment opportunities, such as pre-negotiating services.

Better Health & Lower Costs

The proprietary AWAC® precertification, prescription and claims review software, physician medical directors, specialty physician-to-physician communications, comprehensive provider networks and integrated precertification and utilization management allow AWAC® to quickly identify and manage expensive and potentially expensive cases and to work with the Plan to assure optimal health outcome for the insured.

• AWAC® is saving more than $750,000 a month for one TPA with 45,000 employee lives.
• The AWAC® medical management system has saved its clients in excess of $150 million in cumulative savings.
• In 2006, average cost reduction for the claims that AWAC® worked was 43%

In addition, many MGU’s/reinsurance companies offer premium consideration to clients that rely on AWAC® and/or iProcert™.