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RB-UCR Resource Based Usual, Customary & Responsible

The responsible way to establish allowances

AVS-RB-UCR is a fair and reasonable tool for establishing pricing benchmarks and payment thresholds for physician medical services. It carefully blends statistical charge based data with actual costs for a reasonable and responsible pricing benchmark for both in network and out of network services. Utilizing RBRVS as a pricing benchmark RB-UCR utilizes industry developed cost indexes which are geographically adjusted to reflect cost and charge differentials.

The new wave for pricing

Now you can build your own pricing processes within your legacy payment system to price claims for Medicare and commercial plans. Use a pricing benchmark that is based on reason and fairness.

AVS-RB-UCR Features

  • The RB-UCR Usual, Customary and Reasonable Replacement pricing process consists of all necessary knowledge bases for pricing claims and establishing allowances for the payment of claims
  • The data has been codified in flat files for easy integration into the claims adjudication process work flows.
  • The pricing benchmarks in standard form are geographically adjusted by state. Additional options are available to provide pricing adjustments by specific zip code ranges.
  • Perform RBRVS pricing and editing either on an integrated basis within the claims adjudication process or on a stand-alone basis.
  • Date-sensitive databases for easy updating
  • Semi-annual updates.
  • Easy to program integration instructions
  • Pricing for both out-of-network and PPO contracted networks
  • Includes CPT(R) descriptions - CPT is a registered trademark of the American Medical Association.
  • Includes complete table of mutually exclusive and unbundling tables (NCCI)

AVS-Advanced Value Scale built on national standards

RB-UCR is a component of W.O. Comstock & Associates' Advanced Value Scale (AVS) coding compliance and management system and the values developed are blended with charge based statistical data and updated semi-annually. RB-UCR can be operated on a stand-alone basis or integrated within any claims administration system. Relative values used within our data development process are based on actual resource used and consist of the actual work, intensity, time, difficulty, expense and risk associated with the procedure.

AVS is an integrated coding and reimbursement system based on RBRVS pricing and nationally recognized correct coding methodologies. AVS is built upon standard CMS policies as defined by the National Correct Coding Initiative. It is a responsible reimbursement process that provides a platform for a National Standard that is reasonable and defensible and can lead to more effective care management and cost containment. AVS is a common reportable language that can benefit physicians, payors, and patients alike.

The AVS advantage

  • It is built on National Standards
  • Assures uniform payment policies and procedures
  • Physicians recognize the policies and conform to the policies
  • Inexpensive
  • Perfect yardstick to measure performance (numerical measurement without emotion)
  • Easy to sell to providers and payors because it is reasonable and responsible
  • Reduces the need for complex formulas associated with UCR-based systems
  • Accommodate the managed-care model

The RBRVS platform for uniform standards

RBRVS is a pricing system developed by a research team at Harvard University School of Public Health under contract with Health Care Financing Administration. The RBRVS has been developed and implemented by order of law from Congress to reform payment to physicians for Medicare services. Medicare began using RBRVS for payment in 1992. Since then, most major and many minor insurers have adopted it for payment of fee-for-service medicine.

Each HCPCS code has a value that equals the total physician resources required to perform the service. The value consists of three components measuring resources: work, practice expense, and malpractice. The combination of these three components equals the total value of the procedure. Conversion factors are the multiplier that transforms relative values into payment amounts.

RBRVS is updated each year through a cooperative effort with CMS, AMA, and Medicare Carrier Medical Directors and all recognized medical specialty societies. Medicare conversion factors are created through congressional order and change every year.

Whenever a service is altered in some manner (multiple surgery, assist at surgery, etc.), the value is also altered since the RBRVS value is a measurement of the resources required to perform the service according to HCPCS description. Thus when a service is altered, there are accompanying payment policies that also alter payment amounts.

The RBRVS advantage

    • Provides a platform for a national standard that is reasonable and defensible
    • Payment is based on resources used to perform services and not on an arbitrary fee
    • An effective cost-containment tool that enhances managed-care initiatives
    • Provides data analysis that is comparable to others

Frequently Asked Questions

What does AVS RB-UCR provide? We provide you with an easy to implement and use replacement for determining an acceptable and allowable reimbursement fee for your payment system to consider. It is a pricing benchmark that eliminates over billing and excessive fees. We also provide unbundling tables at no additional cost.

What is included in the medical module? Includes E&M, medical, surgical, radiology, laboratory and pathology procedures.

How does it differ from other charge based UCR systems? There are several distinct differences. Although all products of this nature will claim to provide the same pricing function, you will find that a full statistically based process has a built in cost creep. Historically, UCR fees are arbitrary with no sound logic. Billed fees for the same procedure can vary by as much as 400% within a specific city or town. When the majority of the providers in a specific geography all over bill. That rate becomes the acceptable UCR standard. AVS differs by;

  • Saves approximately 10-15% over standard charge based pricing
  • Levels the pricing within a service category (Brings up the below acceptable price levels and lowers the overcharged procedures)
  • Utilizes resources used to deliver the service
  • Integrates NCCI (National Correct Coding Initiative)
  • Eliminates unbundling of codes
  • Easy to implement in the adjudication process

Does AVS-RB-UCR provide for different percentiles? Yes…AVS-RB-UCR provides the ability for the payor to select from 8 percentiles including… 50, 60, 70, 75, 80, 85, 90 and 95.

Can AVS-RB-UCR price in-network claims? Payors who have contracts with providers should always pay claims based on the terms of the PPO contract. In cases where no contract is used, or in cases where you wish to establish a fair and responsible reimbursement level, RB-UCR can be used. These thresholds provide a fair and reasonable benchmark for you to compare pricing.

How is the data organized? We provide 2 databases for pricing and one additional database for the unbundling codes. These are all date sensitive and allow our clients to maintain pricing processes for multiple dates of service periods.

Is the data geographically organized? Yes…the pricing is adjusted by state and provides appropriate adjustments based on the cost differentials.

What is the extent of the programming required to implement? You will need to create data files on your system to load the data. After which, you will then need to create 2 subroutines. One for the pricing formula and one for the unbundling formula. Both of these require very simple logic and formulas.

When a claim line is denied, what language or reason can be used? We have enclosed correspondence language that explains the policy violations for the mutually exclusive and the unbundling violations.

AVS is a defensible system…How do you respond to providers that dispute the values? AVS is based on national standards…you should have a form letter developed which contains the following text.

The pricing benchmarks for determining our allowable fees have been developed through a blending of actual resources used (RBRVS-RVU) with geographically normalized statistical UCR charge data.

The pricing and coding methodologies utilized within the development of the relative values have been developed in accordance with methodologies recommended by the National Correct Coding Initiatives and the Centers for Medicare & Medicaid Services' Bureau of Program Operations (BPO). The coding edits included within AVS are designed to control improper claims billing. The coding conventions and policies developed closely conform to those defined in; the American Medical Association’s 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.

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