AWAC, LLC
Description | Challenge | Solution | Outcomes | Additional Info | Time Investment | Lessons Learned
Description
AWAC, LLC has created a technology-driven, physician-based approach to identify & intervene before claims are paid, indeed, often before expensive claims occur. AWAC® uses its technology & physicians to optimize medical outcomes and minimize costs. AWAC®’s strategy is unique in the industry & its proprietary algorithms were created its physicians.
Challenge
Typical reactive medical management and cost containment efforts are generally fragmented and based upon retrospective review of paid claims data. AWAC® pulls together real time data from a multitude of sources for immediate review by physicians and other specialists in order to facilitate prospective review, analysis and preemptive actions by its group of clinical and financial experts.
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 peer-to-peer with providers. It takes a board certified physician with hands-on experience in the specialty in question to communicate with attending physicians, manage expensive cases, review coding and billing in a clinical context & personally negotiate claims.
Self-insured employer groups, health plans, 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, but also to have the intervention tools and skilled professionals to provide effective medical and financial management to ensure quality care, avoid variances and contain costs.
Solution
Better than predictive modeling, AWAC®’s technology-enhanced longitudinal approach not only finds the issues and opportunities, its physician-led, multidisciplinary team provides the solution. AWAC® offers comprehensive, nationwide medical management services that are not limited by diagnosis or problem; some include:p>
- Early identification of catastrophic cases (clinically or financially)
- Pre-admission negotiations
- Physician claim review and negotiations
- Cost management programs for:
- end stage renal disease
- implants
- cardiology
- orthopedic
- oncology
- neonatology
- pain management
- specialty medication
- transplants
- Precertification and utilization review
- Multidisciplinary care management teams
- Comprehensive wellness education
- Disease management
- Interventional nurse coaching
Outcomes
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 80,000 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. AWAC® securely downloads and scans claims data, prescriptions and pre-certification records. By comparing these to information in more than 50 separate databases, the program identifies cases that offer opportunity for clinical improvement or financial savings. The software also recommends possible actions. AWAC®’s physicians then review the cases the program identifies and perform customized reviews based on their knowledge of insureds, providers and the Plan. This all happens daily -- before the claims are paid.
Step 2 - Medical Management: Contributing to AWAC®’s success is a passionate, dedicated team of board certified physicians who monitor the data and serve as on-call medical directors, managing the cases identified. 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, AWAC’s physicians 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 personally review billing to provide clinical correlation, make sure the procedures were done and coded correctly and finally make sure prices are reasonable – things they know first-hand. If they identify questionable items, they discuss and negotiate, often 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, AWAC 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, implants, organ transplants, neonatology, diabetes management and many others.
Step 4 - Medical Precertification and Utilization Review: AWAC offers an array of physician-led utilization services with iProcertPLUS™, totally integrating utilization management into the AWAC® system of cost reduction and disease management options.
iProcertPLUS™ is 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, disease management requirements or potential cost containment opportunities. This integrated approach affords significant pre-service negotiating opportunities by AWAC® physicians.
In 2008, iProcert™ outcome was 57% better than Milliman’s national average for admissions and 27% better for days per 1000.
ROI
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 cases and to work with the Plan to assure optimal health outcome for the insured.
- In 2008, AWAC® saved one 33,000 ee group over $11,000,000 (hard dollar savings).
- In 2008, AWAC® saved 46% over and above other network pricing and discounts in place.
In fact, AWAC®’s strategy is so effective, many companies offer stop loss premium consideration to clients that rely on AWAC® and/or iProcert™.
Additional Information
AWAC, LLC currently works with self-funded, self-insured employer groups, third party administrators, large health plans, managing general underwriters and reinsurance carriers.
AWAC is currently providing medical management and cost containment solutions for nearly a million covered lives.
Time Commitment for Implementation
Planning cycle: 1-3 months
Implementation time: 30 days depending upon the size of the population and client IT systems
Lessons Learned
Real time electronic medical data surveillance with specialty physician review and intervention before claims are paid is far and away the best approach to optimizing health & minimizing health plan expense. This unique health risk management program is only available with AWAC®.
