Augustus HCS offers a value-add service to TPAs/Payers that goes beyond the capabilities of standard auto-adjudication software. We achieve pricing efficiency post-billing through network discounts and repricing initiatives.
The medical necessity of some services is found in many instances to be questionable. These questionable issues cause payers large sums of money and the instances of abuse is skyrocketing. When a mismatch occurs between clinical documentation and coding (ICD-10/CPT-4 and HCPCS-II coding), it becomes the basis of our repricing and negotiations.
We also work with providers to reduce unbundling and over coding issues. Augustus HCS has identified that high-value services, including 4th and 5th level evaluation and management (E/M) codes and surgical procedures performed in the operating room, often lack supporting components, such as documentation of service duration. We challenge these undocumented services with the help of our medically qualified clinical staff within Augustus HCS.
Our clinical staff apprises the clinical documentation based on evidence driven medical procedures by applying tools such as InterQual criteria and the Milliman Care Guidelines (now known as MCG) for an appropriate utilization review.