Advanced Integrated Systems--Benefits Of PAS To All Stakeholders

Provider Access System

The Provider Access System (PAS) was developed as a venture between Advanced Integrated Systems, Prospective Health Inc (PHi), a wholly owned subsidiary of McKesson HBOC (a Fortune 50 company), and Health Adjudications Systems (AIS’ equity partner). PAS is an online, real-time electronic health claims adjudication system for all provider types – medical doctors, dentists, pharmacists, hospitals, opticians, labs/diagnostic centers. It allows claims to be submitted for adjudication and to be paid instantly (less than 10 seconds in total). In the event that claims cannot be paid, a notification to that effect is transmitted to the provider's computer (also in 10 seconds or less), along with an explanation as to why the claims cannot be paid.

PAS delivers benefits all around:

Benefits To The Insurance Carrier:

PAS is an end-to-end claims processing solution. Through the use of drug codes, CPT medical procedure codes, ICD-9 or 10 diagnostic codes and ADA dental procedure codes, benefits, plans and attendant business rules can be defined down to their minutiae—and PAS will adjudicate online real-time with absolute precision! Consequently, the advantages of having providers enter claim data at the point-of-service, coupled with the benefits of online adjudication and PAS providing all the reporting (including cheque-printing and/or bank transfers for provider payments), its efficiency and cost-effectiveness cannot be surpassed.

PAS allows for an unlimited Health Insurance portfolio, as well as boundless Provider growth (INTER- OR EXTRA-REGIONALLY)--all with a limited increase in fixed costs!!! Upon introduction, PAS promises a significant decrease in fixed costs. These reasons alone are enough to justify using PAS as a claims adjudication solution, but let’s examine the many other benefits of adopting the PAS approach:

PAS removes the burden of manually entering (key punching) claims (transactions).
PAS guarantees the completeness and accuracy of data elements used to process claims.
PAS provides greater flexibility in structuring and monitoring benefits, especially rules governing individual prescription drugs.
PAS monitors the use of generic drugs, as well as contracted individual drug prices between the carrier and any one or group of pharmacies--and it does so online, real-time!
PAS allows for the development of benefits across provider types. Such benefits can be governed by limits on any combination of period, monetary maximums, occurrences, per diem maximums, lifetime maximums, etc; thus resulting in absolute actuarial flexibility in the development of plans.
Pro-Analyst (the carrier's database), facilitates extensive portfolio analysis to enhance decision-making support and strategic planning.
PAS provides real-time information on rejected claims, which can be accessed immediately through the help desk feature (thus enhancing customer service), or stored for analysis at a later time. Such information can be used as a renegotiating tool for extended benefit packages.
Earlier payments to providers will motivate the provider base, yet will not have the presumed negative effect on cash flow because point-of-service adjudication can be used to leverage earlier premium payments.
The e-mail facility interwoven into PAS' development not only drastically cuts carriers' communication costs, it also facilitates automatic communication with the "prescriber" to authenticate each claim.
Because providers and carriers share the transaction fees, neither has to bare the full burden of the expenditure.
PAS is administered from a Fault Tolerant Service Bureau, and comes with 24-hour a day/7 days per week help desk support.
PAS can adjudicate for foreign carriers (as long as those carriers conform to Envoy standards).
The electronic transmission and receipt of claims adjudication information between the provider and the carrier will take a maximum of 10 seconds.
PAS makes it possible to eliminate or greatly reduce the misuse of health cards.
PAS produces a multiplicity of reports to enhance management control and assessment of any or all aspects of the business.
PAS facilitates electronic pre-authorizations.
PAS maintains subscribers' confidentiality by eliminating the need for paper forms which can be viewed by several unauthorized individuals.
PAS significantly reduces subscriber fraud!
It is important to point out that PAS is not intended necessarily to replace your present claims processing software, though its benefits are likely to suggest that you do so. If you elect to replace your present claims processing system, you may do so on your own timetable while PAS continues to work for you, maximizing profitability and enhancing the management of your business. PAS' EPOS can sit between your claims system and your provider client base, adjudicating claims and updating ProHealth its claims system online, real-time, and producing a wealth of reporting . PAS provides for the transfer of transaction updates for your back-end and for printing cheques via ProAnalyst and ChequeScribe. By use of IPOS (the internal POS used by the carrier) the loading of eligibility updates of member and plan data from your claims system is easily accommodated.

Click here to read two articles written by Douglas Halsall, CEO of AIS. These articles speak to the state of today's health insurance industry, and explain in detail how the Provider Access System can help!

Click here to view a PowerPoint^® presentation on the "Tools and Rules" of Prohealthi--the adjudication application.

Benefits To The Provider:

GUARANTEED PAYMENT FOR EVERY INSURANCE CLAIM WITHIN DAYS (INSTEAD OF MONTHS), IS ENOUGH REASON WHY ALL HEALTH CARE PROVIDERS DESIRE PAS, BUT LET US EXAMINE SOME MORE:

PAS verifies subscribers' eligibility before healthcare services are provided and/or medications are dispensed.
PAS eliminates the need to manually update paper health cards.
PAS eliminates "bounced" claims due to errors or omissions in claims preparation, or due to policy cancellations.
PAS claims get preference over paper claims, as money is committed to PAS claims as soon as the electronic claim is submitted.
PAS enhances Providers' cash flow--and its predictability--by guaranteeing payment within 7 working days.
PAS eliminates the need to complete, submit and reconcile bulky Health Insurance Claim forms.
PAS stores a copy of all electronic claims on your computer, so you can retrieve them at will.
PAS provides you with a number of helpful Cash Management, Reconciliation and Claims Summary Reports.
PAS comes with 24-hour Help Desk Support (for those who sign AIS' Provider Service Contract).
PAS can be customized to meet your security needs.
- Each person can have access to different areas of the database.
- Diagnostic codes can be hidden from non-essential personnel, thus maintaining doctor-patient confidentiality.
- Claim reversals can be blocked unless authorized by you.
- No outsider can view your data without your permission!
Coming Soon:
- Drug interaction checks will automatically be performed by PAS. Not only will drug interaction checks be performed for the prescriptions being filled in a particular instance, but PAS will also check its database for potential interactions with other drugs recently dispensed to the same patient.
- Free e-mail and access to relevant web-based local and international healthcare information.
- An alliance with local banks to facilitate credit/debit card processing at a reduced hardware rental rate.
- Adjudication of inter- and intra-regional carriers' claims.

Click here for screen shots and a description of EPOS-- The Provider Interface Application.

Click here to view a detailed PowerPoint^® presentation on the EPOS.

Benefits To The Subscriber:

PAS is a paperless health claims adjudication solution; therefore, patients' confidentiality is preserved because others cannot view their procedure and diagnostic information.
Customers and patients will receive faster service, as it is not necessary to spend time manually updating paper cards, or checking large print-outs for eligibility status..
Patients can use an Interactive Voice Response (IVR) System (which they can access via telephone), to check their balances.
Electronic swipe cards are much easier to handle and transport compared to bulky paper cards.
PAS enables a hassle free adjudication of health claims, treats with all provider types, eliminates the need for subscriber claims and the attendant wait for settlement. It amounts to a simplified health insurance environment with no more hassle than the utilization of a debit or credit card.
In the future, smart card-based health cards will store detailed health information (allergies, etc), and will act as personal identification cards which contain biometric parameters.

Benefits To Collectors of Epidemiological Data

Because the Provider Access System is an online, real-time health insurance claims processor, which requires that a procedure and a diagnosis code be submitted with each medical claim, it is the ideal medium through which critical data can be reported to local and regional epidemiologists on a daily basis!. The application is written in such a way that Providers (i.e. doctors, hospitals, etc.), are inclined to use PAS for more than merely adjudicating insurance claims. For example, Providers can use the patient transaction history information that is updated each time a card is swiped, to handle patient billing. Because patients' transaction histories are stored locally on each Provider's machine, the information contained therein serves as an invaluable reference for Providers.

Benefits to the Public Sector

In many countries the Public create and administer their own health plans. PAS in an ideal solution in such locations because it offers the public sector administrator all of the benefits and savings enjoyed by insurance carriers, at a fraction of the costs associated with outsourcing.

Benefits To The National Health Plan Administrator

In addition, some countries like Jamaica offer a National Health Plan which reimburses its citizens for drugs (according to the price of the corresponding generic item), used to treat some 16 chronic diseases. Drug treatment schedules can be set up for each disease within the PAS database, and the system is updated with appropriate information when a citizen is certified by an appropriate physician, as having one or more of the pre-defined chronic diseases. The citizen is issued a magnetic strip I.D. card, which is required to initiate a claim at participating pharmacies. PAS handles all of the monitoring thereafter, ensuring that there is no abuse and that no one gets more or less than they are allowed under the program.

Benefits To The Public Sector Hospital

Some Public Sector hospitals adopt a policy of not refusing service to a patient who is unable to pay. This is noble, yet expensive (and at best, difficult to monitor). Experience has shown that many who profess an inability to pay, are in fact being deceitful. Some have undeclared insurance policies, while others are financially able.

PAS, with the permission of participating insurance carriers (and this can be encouraged), will transmit a name enquiry through to the various databases to establish the health insurance status of the relevant patient. Hospitals should be advised that cooperation is not likely (from insurance carriers or from patients), if higher rates are charged to those "with means."

PAS, being an online system, can be directed to communicate with other databases that the Public Sector may have, to establish "means." This liability to the Public Sector can be logged in important databases where "more leverage" in the collection effort can be exercised.
PAS, if installed with the optional Accounts Receivable module, will automatically charge such unpaid sums to an account established in the name of relevant patients. This information can be used for future follow-ups, and outstanding balances will be prominently displayed on the patient's next visit.

Benefits To The 3^rd Party Application Developer:

AIS marketing strategy from the very beginning anticipated PAS being integrated into other 3^rd practice management or other software, providing the transaction processing front end through its EPOS (External POS) to allow online, real time electronic adjudication of claims.

Benefits to the Local ("In-Country") Business Partner

Our partners will not only benefit from a generous share of the transaction fees, but they will also be given preference to represent many of the third party applications that have been integrated with PAS. Such applications may include Practice Management software for doctors and dentists, pharmacy POS and inventory applications, hospital administration systems, etc. In addition, our partners will be eligible to receive a portion of the training, installation and consultancy fees, as well as some of the hosting fees associated with implementing PAS in each country.

For the Investor:

A good idea must be shared. AIS markets PAS overseas by seeking business partnerships with IT houses that have infrastructures suited to transaction processing, and with interested investors who see the financial benefits offered by transaction processing. Potential partners should be capable of marketing effectively within their own territory, and be willing to enter into a processing arrangement tailored to the nature of each marketing environment.

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