Cost Containment, Audit and Review Service (CCARS)

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Getting Money Back As Easy as 1,2,3

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.

Evaluates the Effectiveness of your Payment Process

The claim batches can be from any external claims payment source and can arrive in any format. Utilizing our Advanced Value Scale 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 provider coding errors and/or payor payment processing errors.

Why Doesn’t My Current Plan Do this for me?

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. This is undoubtedly contributing to why there is roughly 100 billion cases 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.

  • Identify inappropriate coding
  • Identify overpayments
  • Spot billing errors
  • Recover lost dollars
  • Reduce claims expenses
  • Improve payment effectiveness

Advanced "expert processes"

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.

Defensible Policies

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, the Centers for Medicare & Medicaid Services' Bureau of Program Operations, and the RBRVS Update Committee. The methodologies 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.

On Site or On Line, Drill Down Access To Claim Errors

The CCARS service can be performed off-site with information sent to a 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.  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.

As Easy as 1,2,3….Powerful Reporting and analysis

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-up site review and investigative services, they represent a powerful offering that can reduce claims payment errors and improve the effectiveness of the health plan. Remember these are just some basic examples.  Additional reports and analysis can be customized for any needs.

1.  Loads Client Data (Create Client Detail From Raw Data):

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 knowledge base. Once claims data is provided, no other actions are required on the part of the client. All processing will occur at W.O. Comstock & Associates offices.

2.  Creates Client Data base (Run AVS);

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.

3.  Create Client Claims Warehouse (Create Summary Work File);

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 report contains all claims and is seldom printed because of its size. It is used as an electronic repository for specific claims information identified in subsequent benchmarks.

Summary reports provide specific totals for each of the audit category flags and individual AVS edit flags. They provides claim numbers, member IDs, provider IDs, CPT(R) codes, submitted amounts, reduced amounts, allowed amounts, and actual payment amounts.

4.  Identify Outliers (Update client claim data with U&C);

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.

5.  Claims Snapshot (AVS Statistic Summary Report);

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. Created is a one 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 reductions, and total of audit reductions.  This provides a quick thumbnail sketch of the audit.

6.  Drill Down on Specific Claims by Error Code (Client claim inquiry by audit code);

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.

7.  Fraud and Savings Opportunity Report (AVS Audit category Summary report);

Using the AVS summary work file as an input, the AVS Audit Summary By Type and Category is created.  It consists of a three page summary report by audit code listing audit count, submitted, reduced, allowed, 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.

8.  Drill Down Fraud and Savings Detail (Savings Opportunity Exception Report;

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.

9.  Fraud and Savings by Severity Level (Detailed Audit flag exception report)

Similar to step 8, it 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.

11.  High Value, High Usage Summary (Procedure Summary Report);

Using the client claim file as input the Procedure Summary Report summarizes each claim line by procedure code.  This makes it possible 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 member's claims or individual lines (detailed) for each claim. It provides a means to identify by member, high dollar abuse situations.

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