Avandé physicians determine when healthcare procedures or services are medically necessary. Medical necessity is determined from the client’s Explanation of Charges (EOC), review of the applicable medical policy, clinical practice guidelines and a review of the relevant medical literature.
We apply our proprietary algorithms to review physician, facility, and other provider claims from clearinghouses or our client’s servers. These algorithms identify overcharging, resource over utilization, fraud and abuse, and medical missteps.
We add contracted or network preferred provider information including location and availability to medical necessity decisions. This enables our clients to determine where patients may be referred for care, ensuring that they receive the right care, in the right setting.
Forensic review drills down to specific charges in claims that fall outside valid reimbursement criteria due to overutilization, violations of medical policy or abuse. Forensic reviews include detailed written reports that contain clear, referenced explanations.
Avandé monitors inpatient care from admission through discharge. Board-certified specialty physicians review daily progress and identify variations from expected recovery guidelines. This allows for real-time peer-to-peer intervention to optimize healthcare quality.
Avandé educates providers, health plans, and employers about clinical practice guidelines that can significantly improve the health of patients, members, and workers. Avandé helps to speed utilization of updated practice guidelines so that everyone can benefit from recent advances in medicine.
Avandé Intelligence (AI) is the only fully integrated application connecting prior authorization and claims payment with real-time complete analysis of coding error identification, bundling and unbundling, experimental and investigational codes. Reference based pricing can be implemented using DRG (inpatient) or APC (outpatient) pricing when needed with and without outlier provision.
Current Preferred Provider Organizations (PPO) networks attempt to offer discounts for Payers. However, clients are still paying 300-500% above cost. Avandé has developed its own Private PPO network to obtain optimal value for healthcare services and retaining the right to audit healthcare invoices for overutilization and fraud.
Today, especially in view of the pandemic, every employer is a healthcare company. It does not matter if your company is an airline, restaurant, hotel, movie studio, college or university, or delivery service, the health of your staff is crucial.
Avandé has access to timely, actionable intelligence from regulatory agencies, health monitors, pharma and device manufacturers, and scientists worldwide. We can help you anticipate and proactively respond to healthcare trends at the macro and micro level.
Avandé provides relevant, industry-specific recommendations to help you navigate change and uncertainty. Avandé’s physician specialists are a valuable resource. We can provide expert advice or can even serve as a virtual CMO for your company.
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