Advanced Integrated Systems--Healthcare Industry Solutions

AIS' is committed to providing the healthcare industry with technology-based solutions that increase efficiency and decrease expenditures. Our endeavors are currently centered on a unique and multifaceted product dubbed the Provider Access System (PAS). A brief overview of PAS, its structure and some associated benefits are discussed below. Carriers will be happy to learn that PAS is a tool that makes inter- and intra-regional expansion possible--without the need to replicate administrative and most other fixed costs.

The Provider Access System (PAS) is an online, real-time health claims adjudication system that can accommodate all types of healthcare providers (medical, laboratory, hospital, pharmacy, optical, diagnostic and dental). PAS allows providers to perform online, real-time eligibility checks prior to rendering services or dispensing medications. In so doing, PAS confirms patients' and customers' status with an insurance company before any of the provider's resources are expended. Upon completion of the eligibility check, providers can officially (and electronically) submit a claim (online real-time) directly to an insurance carrier using PAS. In this way, the provider's payments are guaranteed, and the paperwork associated with submitting health insurance claims is reduced to subscribers signing a PAS-generated receipt, which produces an audit trail for the Carrier.

All of this is facilitated by a one-of-a kind, first in the world, online real-time claims processing application that for all its sophistication, is intuitive and permits Carriers to easily set up all of their plans and associated eligibility rules in an Oracle database. Industry standard codes such as ICD 9/10, CPT, ADA and drug codes are used as building blocks, along with editing tools such as: quantity over time, benefit and plan maximums, exception lists, number of occurrences, UCRs, etc., to define benefits down to their minutiae. PAS will adjudicate any claim--base or major medical--within 10 seconds and provide both the Carrier and the Provider with the finest audit trail for easy reconciliation.

Redundancy is a hallmark of PAS' design, and "simplicity" is a word that our users frequently associate with the Provider Access System. Since its network is based on IP/VPN, we have introduced e-mail to facilitate Carrier-to-Provider and Provider-to-Provider communication. This has enhanced communication tremendously whilst reducing paper and allied costs to their barest minimum.

PAS was developed as a joint venture between PHi of Chicago (a fully owned subsidiary of McKesson HBOC), Advanced Integrated Systems of Jamaica, and Health Adjudication Systems of Grand Cayman (AIS' equity partners).

First, an insurance carrier must precisely define its business rules (plan limitations, prior authorization requirements, eligibility parameters, etc.). Additions, terminations and other changes will be made via system updates, as necessary. PAS can be used with (or instead of) a carrier's existing in-house claims processing application. If PAS is used in conjunction with a carrier's software, daily batch files containing eligibility status and information related to claims "paid" (authorized) by the online system (PAS), will be exchanged to ensure that both applications are kept in sync.

AIS encourages all application developers in the healthcare industry (including those who develop pharmacy applications), to integrate PAS’ claims processing formats into their applications. Should a Provider elect not to use a product from the growing list of third party applications into which PAS has been integrated, AIS' own Provider application can be installed. All relevant databases will be setup on the Provider’s computer, and AIS will coordinate and facilitate all training. The application is intuitive and user-friendly, thus training usually takes hours instead of days--even for those who have limited familiarity with a PC. Our application is known as EPOS (External Point of Service), and it should never be regarded as a compromise to the average Practice Management application. More can be learned about EPOS from our PowerPoint presentation on this site. The basic requirements for EPOS include a PC w/64MB RAM, 6GB Hard Drive, a magnetic strip reader (provided by AIS), and receipt printer. A network version of EPOS is available for larger Provider sites such as hospitals.

Authorization numbers are assigned to "paid” claims and are then associated with the return transaction, thereby contributing to the audit trail. Of equal importance are the coherent explanations associated with rejected claims. Whenever a claim is rejected, PAS notifies the Provider as to the exact reason why the Carrier won’t pay a particular claim. Common reasons for rejection include: patients not having sufficient funds to cover the services being rendered; a particular procedure or drug not being covered by the subscriber’s plan; and the Provider not being authorized by the Carrier to render the service (or dispense the drug) being claimed for.

The following databases of codes are recommended (but not mandatory) in setting up plans and submitting claims from EPOS:

The aforementioned databases are provided with EPOS, which also includes extensive prescriber and drug databases, wherever relevant. Note that the most complex plans can be structured by using these databases, and that a single plan can include multiple provider types, all with a guarantee that electronic adjudication will take place in under 10 seconds!

Where PAS is being used as the sole claims processing engine (and optionally where it is not), IPOS--a derivative of EPOS--is used by the carrier in-house to submit paper claims. Since PAS was designed with a parameter driven infrastructure and an intuitive graphical user interface (GUI), training (both for carriers and for providers) is neither burdensome nor time consuming.

Enhanced communication between carriers and providers, as well as between providers themselves, is a major hallmark of PAS. The Provider Access System employs a country-wide Internet Protocol/Virtual Private Network (IP/VPN) extranet that facilitates e-mail and other convenient (and cost-effective) methods of communication. PAS can be set up on an inter- or intra-regional scale, thus providing tremendous opportunities for a carrier's expansion--opportunities which don't require the duplication of administrative overheads.

Click here for more information about how PAS benefits carriers, providers, subscribers, epidemiologists and the public sector.

AIS is looking for suitable business partners in every country. In you are an insurance carrier, provider group, etc. that is interested in PAS, please click here for our contact information, or write to info@aiswebnet.com.

Click here to learn more about PAS, including integration strategies, future enhancements and order & pricing information.