AVS Reimbursement System

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W.O. Comstock & Associates 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 methodologies to price claims.  It also identifies physicians claim coding errors and manages 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.  This produces significant hard-dollar savings through the elimination of payments for miscoded and mispriced claims. These powerful knowledge-based processes can be ran 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.

The 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 benchmark not only for pricing claims but also for measuring provider performance.  It provides powerful information to monitor and improve health plan cost-containment strategies.

The AVS Scale systems is available for IBM's AS/400 Advanced Series platform. The system is complete and includes all of the necessary databases, rule sets, and software. It is highly refined 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 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 customized to the specific payment provisions of a health plan. The coding guidelines can also be customized by specialty within specific groups or plans.

CUSTOMIZATION

The systems architecture allows for every component of the system to be customized. This flexibility 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, 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 including: (over 115)


  • Pricing/Code Status Injections (J-codes)
  • Modifier Global Surgery Site of Service
  • DME (Durable Medical Equipment)
  • PC/TC Bilateral Surgery
  • Global ZZZ Team Surgery
  • Billable Medical Supplies
  • Mutually Exclusive (2 types)
  • ICD-9 to CPT(R) LAB*
  • Unbundle (12 types)
  • Assist at Surgery
  • Multiple Surgery
  • Co-Surgeons

*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, HCPCS, policy manuals and coding rules that back up your coding decisions. All of the data is date sensitive and updated 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
  • UCR Individual Provider Overrides
  • Includes Complete Fee Schedule (CPT(R) and HCPCS)
  • Individual Pricing Sheets
  • Conforms to CCI Obsoletes
  • OLE Compliant Prints
  • Pricing Tables
  • 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
  • Codes/Modifiers/ICD-9 requiring documentation support
  • E & M Allowed
  • Surgical Episode Tracking
  •  Unbundling and Mutually Exclusive Code Sets
  • DME Fee Schedule
  • J-Code Fee Schedule
  • ICD-9 to CPT(R)
  • ICD Level of Specificity
  • LAB Fee Schedule

W.O. Comstock & Associates builds strategic partnerships to help our clients make better reimbursement decisions. Complete systems are licensed on an annual basis with multi-year arrangements available. Data is updated every three months. The annual fee provides program error correction service and toll-free help desk support. Optional clinical support services are available that provides edit and policy interpretation in support of the claim-edit processes.

SYSTEM REQUIREMENTS

  • 496 or greater of IBM AS/400

  • 260 MB DASD

  • Compact Disk(CD's)

LICENSE USE AND PROTECTION OF PROPRIETARY INFORMATION

The information contained in AVS is proprietary to W.O. Comstock & Associates, LLC. 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 W.O. Comstock & Associates, LLC. and its licensors. Notwithstanding anything in this Agreement to the contrary, W.O. Comstock & Associates, LLC. 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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