Prong #5 – AWAC

Managing general underwriters and carriers know that the greatest impact on a health plan's costs comes from large individual claims. Therefore, it is critical to identify these cases early, before they escalate into catastrophic claims, then provide effective medical and financial management to ensure quality care, avoid variances and contain costs. To quote the Secretary of Health and Welfare, Mike Leavitt stated "I will show you the most expensive medical device in the system. It's a pen in the hand of a physician. There's dramatic differences in the cost of health care when a pen is in the physician's hand, one physician and another."

Yet most claims analysts simply don't have the expertise to identify catastrophic cases early, to 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.

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. IHS 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.

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 IHS 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 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.

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 IHS 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.

Sound complicated? That's where we come in. Call us at 1-888-298-9845 and we will answer any questions you may have.

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