The continuing evolution of the Predict Suite of solutions from AMS has never been so evident with the latest and greatest updates and additions rolling out throughout this year.
AMS continues to grow. We constantly strive to be better. AMS takes pride in our ability to quickly adapt and keep ahead of the competition. And we never rest on our laurels, looking for more challenges to overcome; more things to accomplish. Bigger. Better. Faster. More. That’s the objective. Here’s an overview of how we’re getting those things done in 2017:
- AMS Cost Projection
- AMS Risk Threshold
- Southern Scripts Pricing (Transparent PBM)
- NDC Information
- Manufacturer Rebates
- Specialty Drug Price Trends
- CPT Module
- Mental Health Sub-Directory
- Bundled Pricing Module
- Live Chat
AMS constantly reviews and analyses the raw data going into PredictRx as well as the algorithms that produce its output. A painstaking examination of its analytics and a further expansion of benchmarks from across the healthcare spectrum have led to an exponential refinement of pricing points. This monitoring process and subsequent restructure has led to the most accurate and up-to-date information available in the industry.
AMS Cost Projection
AMS Cost Projection (ACP) is the latest proprietary innovation to be launched within PredictRx. ACP denotes the usual costs of a given drug within the U.S. healthcare system. This benchmark is calculated using federally contracted rates for government agencies, incorporating amounts paid by any private-sector purchaser for the pharmaceutical. Discounts, rebates, chargebacks, and other fiscal adjustments are all factored into the price. Simply put, ACP is the expected cost for a particular drug dosage amount.
AMS Risk Threshold
AMS Risk Threshold (ART) is the culmination of 15 years of real-world experience expertly reviewing claims for clinical and financial integrity. ART represents a fiscal red line of cost tolerance. This figure is the absolute maximum specialists should tolerate as billed on a claim. Anything approaching—and certainly beyond—this price threshold should be reviewed for additional cost containment. Additionally, in an underwriting/lasering scenario where one has little to no information at hand (other than that the patient will be receiving the drug) the ART is a conservative estimate of what the drug will cost.
Southern Scripts Pricing
AMS has collaborated* with Southern Scripts to offer drug cost ranges utilizing their industry-leading and totally transparent PBM pricing. Traditional PBM pricing is complex; often there are buried charges and other mark-ups which make it difficult to manage healthcare benefit expenses. Leveraging Southern Script’s venerable position in the healthcare field, this new data point serves as an example of the what ideal PBM pricing should be, devoid of any hidden fees or rebates. This is the data that executives, claims managers, sales professionals, and underwriting teams have been clamoring for.
* It is important to note that this collaboration is entirely synergetic; AMS receives no kickbacks or fees for Southern Scripts’ inclusion in the suite. Rather, it is an opportunity to deliver an actionable data point representing industry-leading transparency and pricing. We feel it is in the best interest of all involved to connect our Predict Suite members with other firms in the space that share our goals and vision for a transparent and sustainable industry.
Average PBM Costs
Another drug price benchmark, which goes hand-in-hand with Southern Scripts, is Average PBM Costs. Exactly as the title suggests, this is an aggregate of PBM pricing culled from thousands of Pharmacy Benefit Manager’s data points. This is a min-max range of PBM costs that PredictRx clients should be cognizant of when processing claims.
The NDC, or National Drug Code, is a unique 10-digit, 3-segment number. It is a universal product identifier for U.S. drugs. Users can now search PredictRx for drugs by that code. It is located in the Coding Information section together with HCPCS. Clicking on the NDC tab will show all the NDC Package Codes for a particular drug listed in one column. Alongside are columns entitled Package Description, which itemizes what each package contains, and Strength, which details the corresponding dosages.
Along with the NDC information that AMS has recently added are the manufacturer rebates that may be associated with them. Rebates from manufacturers can be pocketed by PBMs without payers even knowing. AMS has partnered with Health Delegates to give access to the true rebates that are being paid on a per-NDC level. Since PredictRx subscribers would likely never see the information provided here this new data gives visibility into previously unchartered territory, thus levelling the playing field for our clients.
Since the inception of the PredictRx database AMS has been assiduously monitoring the prices of specialty drugs. Price Trending is a new tab within each drug indication. Clicking on it reveals a graph tracking quarterly data of both the AMS Cost Projection (ACP) and AMS Risk Threshold (ART). This visual depiction of the changing costs of a specific drug over the past year is a boon for subscribers who can now leverage that intelligence in order to make informed business decisions going forward.
This module lists CPT codes normally seen accompanying a particular diagnosis. With each CPT code, users will find national, and even state-specific, reasonable charges. The information—commonly used in the industry to set benchmarks for bill audits—is sourced from one of the country’s largest and most reliable providers of Usual, Customary & Reasonable (UCR) charge data. The CPT Module, like other coding information in PredictDx, is viewable in the Treatment Analytics section.
AMS is proud to now have an assortment of Mental Health diagnoses in the PredictDx database. Mental Health is the most expensive health condition in the US, with over $200 billion of spending on these disorders. Opioid abuse, bulimia, ADHD, schizophrenia, anxiety, and bipolar disorders are just a few of the diagnoses implemented specifically for this innovative module. Subscribers can search among behavioral health issues via the drop-down box by selecting the Mental Health option or the “All” option.
A bulk upload of an additional 12 diagnoses has just been launched into PredictDx, the most recent of which is Diabetes Mellitus. Our subscribers have asked about many of these. Since we place great emphasis on being responsive to the needs of our clients AMS is pleased that we can deliver on their requests.
AMS has been meticulously refining the Treatment Analytics section. Specifically, the clinical team has focused on further distillation of treatments and their associated scope of costs. For example, the former line item “Reconstruction” for Breast Cancer has been broken down into the following, each with its own specific charge range:
- Latissimus Dorsi Flap
- DIEP Flap
- Reduction Mammoplasty
- Nipple/Areola Tattoo Pigmentation
- TRAM Flap
- Tissue Expander/Implants
This specificity is designed to allow the user a greater ability to pinpoint charges associated with a particular procedure. The expanded depth & breadth of information provides granularity when needed, yet retains generalized analysis under the Treatment Name section for instances that do not warrant it.
Bundled Pricing Module
The Bundled Pricing Module (BPM) provides the true costs behind 15 of the most costly and popular implant-related procedures—with more being added every month. The BPM not only gives the total costs for these procedures, it also breaks those costs down to its component parts. Furthermore, it also contains complete clinical procedural reviews, CPT, ICD, and HCPCS codes, plus individually listed implant, procedure, and facility fees. Through the data, pricing and analytics within the BPM, payer clients can plainly see how much their claims costs have been inflated. It eliminates any guesswork about how much health care providers should reasonably be charging for the most common implant-related features.
A live chat feature has been implemented in ImplantDx as well as throughout the entire Predict Suite. AMS understands how important it is to get an issue resolved in a speedy manner. Here are just a few things you’ll be able to resolve via Chat:
- Login issues
- Print help
- How do I use the bulk upload feature?
- What does the AMS Risk Threshold mean?
- Can I schedule time for additional training?
Of course, if the question is more in-depth than a Chat can reasonably address, clients still have the option to call, e-mail, or take advantage of their clinical and underwriting support. The chat function is available Monday – Friday, 9am – 5pm EST.
Lead… Or Get Out of the Way
The healthcare industry is not static. Drug prices, governmental policies, medical protocols & procedures, and systemic industry guidelines are all in constant flux. Advanced Medical Strategies has its finger on the pulse of these ever-changing conventions. Status quo is not an option for us…it never was. AMS continues to push forward, constantly staying ahead of industry trends by utilizing cutting edge technology, data, and information.
Let’s keep going!