AWAC®'s knows when and where lightning will strike!

AWAC® is beyond the "cutting edge" of technology!!
  • Physicians available to you and your staff.
  • Your data downloaded nightly (claims, Rx and precertification).
  • Physicians analyze this data daily.
  • Physicians recommend steps to lower costs.
  • Physicians recommend steps to improve outcome.
  • Physicians available to speak with your insured's physicians.
  • Nurses to facilitate clinical aspects of chronic diseases.
  • Masters level social workers that connect insureds to local resources.
  • Masters level dieticians that educate insureds for optimal nutrition programs.
A Clinical Correlation —An AWAC® Differentiating Asset

Amy, a 45 year old woman presented with an acute viral myocarditis in congestive heart failure. Her primary cardiologist stated — correctly — that she might benefit from implantation of a Biventricular Automatic Intracardiac Defibrillator (bi-AICD) in 3-6 months if she was optimally treated. During her hospitalization, however, she was accidently overdosed with one of her cardiac drugs. Her recovery was complicated by an episode of ventricular tachycardia, a serious heart rhythm that can be fatal. Within the week a bi-AICD was placed and she was discharged to home.

AWAC®'s board certified cardiothoracic surgery consultant reviewed the case. In his report he explained that most of the claim was due to the inappropriate use of the bi-AICD. Payment for the device and its implantation were denied by the Plan.

An appeal was later filed by the hospital. The appeal included a letter from a Certified Professional Utilization Manager, (a nurse from a well known national review company). In addittion, a letter from the attending surgeon was submitted to support the hospital's appeal.

The doctor's appeal stated that he felt the device was needed because of her episode of ventricular tachycardia. However, as our consultant pointed out in his reply to the appeal, the doctor's statement ignored the fact that the direct cause of the arrhythmia was a drug overdose, and reversible.

The nurse quoted guidelines from a standard reference source. However, as our consultant also pointed out in his reply, the quoted guidelines did not apply to the case in question.

Total charges: $141,077.98
Savings: $107,946.39
Payment: $21,535.40

Do you believe a claims analyst would have discovered this error? As you can see from this real life case without the expertise of the board certified cardiothoracic surgeon this claim would have been paid.

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