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Clinical

Tailored Solutions for MDs, RNs, and Clinical Personnel

How AMS Can Help Clinicians

Gaining a clinical perspective means gaining possibilities, comprehension, and strategy. Without a clinical overview, there are missed opportunities to reach the best outcome. AMS physician-led reviews and reporting give you a fuller picture of how treatments relate to costs.

Independent Medical Reviews

Before adjudicating a suspect claim, hand it off to AMS for a full verification. We use our nationwide network of more than 700 multi-specialty physicians to quickly and easily analyze any potential problems and provide a summary of clinical conclusions and rationale behind any discrepancies.

Our Criteria Includes:
Specialist physicians evaluate the record to determine if the treatment is anything but medically necessary. Questions frequently asked include if the care provided was cosmetic, convenience, educational, or maintenance.
We rely on scientific evidence and national guidelines surrounding newly practiced medical treatments to craft a report supported by clinical expertise and medical research literature.
Commonly referred to as peer reviews, AMS reports on quality of care address and/or prevent medical errors by assessing practitioner care. Use these reviews proactively for performance evaluations or retroactively to address sentinel events or Never Events.
AMS is happy to discuss any clinical issue to see if we can assist you with your case. We can assess cases based on benefit coverage under specific plans/policies, whether the length of stay or level of care at a given facility was appropriate, and special circumstances regarding Accidental Death and Occupational Accident questions.

Catastrophic Claims Analysis

Catastrophic claims require a close examination to ensure every component is present and reviewed for cost-effectiveness. All complex and catastrophic claim reviews are physician-led, which means AMS assesses your claim with a deeper knowledge and a higher standard of accuracy than you will find anywhere else. With a UB92 or CMS 1500 form, itemized bill, and operative report, AMS can provide a full assessment of your Catastrophic Claim.

What Makes Up a Complete Claim?

AMS looks over everything in an effort to eliminate ineligible expenses for our clients prior to adjudication. Here’s a breakdown of the components we examine when performing a Catastrophic Claim Analysis:

What Makes Up A Claim

i

Length of Stay

ii

Level of Care Billed

iii

Drug/Treatment Given

iv

Inflated or Unbundled Charges

v

Billing Errors

vi

Document Language (specificity and detail)

vii

Consideration of Payor Politics

viii

Adjudication Options

Underwriting

AMS provides expertise in assessing risks, understanding the nuances and details of clinical prognoses, and conveying their true financial ramifications. We work alongside your existing underwriting department to deliver a wider examination of the risks you face by providing critical details gathered from our knowledge base of physician specialists, provider facilities, and prior client experience. Smarter assessment leads to smarter evaluation of client eligibility.

Additionally, we recommend many MGUs, Stoploss Carriers, Reinsurers, and their corresponding underwriting staff look to our Claims Cost Prediction Tools, PredictDx and PredictRx, as a resource to gather physician-verified data on high cost and catastrophic trigger diagnoses and drug treatments.