| ACE |
In the health care industry, rules are broken every day. The Automated Claims Evaluator (ACE) was created to verify whether or not claims are following the rules and to make it easy for investigators to manipulate data to identify outliers.
Rules can be a very broad term and what that term means can vary from client to client. For some clients, the word rules pertains to Medicare, or it means Medicaid and CHIP, or it could indicate a custom-designed rule-set based on a health plan’s parameters, or even a combination of several different elements. Whatever the definition, AMG-SIU has incorporated those rules into the ACE system and can apply them fully or partially, depending on what is needed by the client down to the individual code.
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AMG-SIU has a team of regulatory experts that track the rules for our clients. That means we have professionals that are constantly reviewing federal and state manuals, monitoring bulletins and researching policies. When a regulation, law or policy that could impact our clients’ claims is identified, they are turned into rules for our clients.
The rules and infrastructure of the ACE forensic editing system were created by AMG-SIU’s team of legal, operational, SIU, and IT experts who wanted to make a system that was customizable and easy for investigators to use. That’s why the ACE system can apply any combination of rules to each transaction line of a claim and can compare it to the client’s entire back history to identify potential fraud, waste and abuse.
The detail that went into the development of ACE is the reason it’s the most comprehensive system available on the market today. The ACE system is so comprehensive that it has been called an automated auditor because it goes beyond surface editing – ACE can review claims from most all in-patient and out-patient health care services and compares it to claims from other providers.
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ACE Reporting and Analysis
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Clients submit previously paid claims data as a baseline for prospective or retrospective claims review. Once data is received ACE uses layered logic, artificial intelligence and data mining algorithms to analyze data on the claim transaction level. The data is compared against all past transactions.
ACE processes the data, providing recommendations to deny, review, pay or adjust claims. More than 100 customizable reports are available on-demand through a HIPAA-compliant secure web interface. These reports are instantly available upon completion of processing for users to access and download.
Report categories include: |
- Analytical
- Financial
- Investigation
- Member
- Monitoring
- Provider
- Prescription
- Utilization
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