Advanced, Quality, Medical Reviews

1. Advanced, Quality, Medical Reviews

2. Founded in 2010, Avandé's quality of service is a direct result of the vast industry expertise and wealth of experience of our management team. Avandé's independent medical review services are tailor-made, prompt, and cost-effective. Avandé adheres to the industry’s stringent protocols with respect to confidentiality, security, quality, and compliance. Our case-specific patient information and industry-standard care guidelines enable us to provide a single source solution for our clients’ managed healthcare administration needs for the following review types.

3. Why Avandé? Our service offering is built on a solid foundation of medical, insurance, and technical know-how. Our industry background and combined experience is the product of our team’s expertise and successes in their fields. Our management team, backed by a panel of 60 physicians and our team of solid industry experts, are the key to our ability to anticipate evolving industry requirements and the changing needs of our clients.

4. Shawn P. Evans Chief Executive Officer & Founder An entrepreneur in medical management and insurance, Mr. Evans has a broad healthcare background and expertise in claims management, underwriting, liability, and medical malpractice insurance. Mr. Evans knows how to secure tangible savings for his clients by providing strategic assessments and executing strategies that are tailored toward each client’s specific needs. Prior to joining Avandé, Mr. Evans founded a successful Northern California insurance brokerage firm. Mr. Evans received his degree from California State University, Sacramento.

5. Advanced, Quality, Medical Reviews

6. THE PROBLEMHealthcare Cost Drivers in US • US Healthcare Budget for 2012 ($4,794 Billion) • Variation in practice ($264 Billion) • Unnecessary care ($659 Billion) • Medical futility • End of life care • Duplicative care • Fraud and abuse ($330 Billion)

7. Some Truths • A multi-faceted approach to attack the cost drivers in the industry is essential. • It is no longer possible to manage claims without a sophisticated and adaptable IT system. • Successful outcomes depend on superior information management. • The introduction of a new coding system in the US with 10X the number of codes will make the IT component ever more critical to success

8. Who are the Stakeholders • ACOs/TPAs • Insurance Companies • Hospitals • Medical Groups • Self-insured/Administered • Consulting Companies • Healthcare Plan Payers • Government • Management Companies • Case Management Companies • HMO/PPO/MSO

9. Critical Components to Managing Losses for a Successful program • Consultant • TPA • Network Access Vendor • Utilization Management Vendor • Plan Document Design • Stop Loss Partner

10. Critical Components to Managing Losses for a Successful program • Consultant • Aligned incentives (incentive pay/ bonus) • Input on program design and other vendor partners • Regular reporting and feedback on program

11. Critical Components to Managing Losses for a Successful program • Network Access Vendor • Aligned incentives (protecting the network or as an impartial arbitrator) • Contract terms that allow for denial of claims and claims audits • Narrow or Broad network to follow the requirements outlined by the plan sponsor

12. Critical Components to Managing Losses for a Successful program • Utilization Management Vendor • Prior authorizations (follows practice and plan guidelines and applies them uniformly) • Medical Necessity reviews (uses clinical guidelines and cites them in their review) • Forensic reviews (backs up decisions through the appeal process also review sample reports)

13. Critical Components to Managing Losses for a Successful program • Plan Document Design • Clearly define contract parameters and review regularly • Exclusions clearly defined and updated regularly • Address standard of care and Experimental/ Investigational issues • Specific Prior authorization for most care with penalties if not followed (except Emergent Care)

14. Critical Components to Managing Losses for a Successful program • Stop Loss Partner • Clearly define contract parameters and review regularly for gaps. Ex. Annual Limits on stop loss • Agree to plan management parameters in advance. If policies are followed claim should be reimbursed as paid • Forensic Audits coordinated between TPA and Stop Loss carrier where possible • Clearly defined review and appeal time limits that follow the Plan Document

15. A Few Success Stories • 54 year old female. Retroperitoneal sarcoma complicated by 6 returns to OR for abscess (NEVER EVENT). Total Charges $2.75 million. Settlement for $129,000. Savings of $2,621,000 • 31 year old female. Congenital heart disease. Admitted to tertiary center for valve replacement. Discovered infected pacemaker. Total Charges $258,717.29. Refunded Savings $258,717.29 by BCBS Plan. • 62 year old male. Received bilateral lung transplant while covertly consuming alcohol contrary to transplant center policy. Total Charges $487,429.70. Savings $487,429.70. • 55 year old female. 280 genetic and metabolic laboratory tests over 7 months. Total Charges $115,318.70. Savings $115,318.70. • 63 year old male. Thoraco-abdominal aneurysm. Off-label repair and use of Factor VIIa. Total Charges $1.80 million. Settlement Payment $185,086. Savings of $1,614,913 • 0 year old female. Born 25 weeks gestational age. 6 months inpatient. Total Charges $1.25 million. Settlement Payment $900,000.00. Savings of $350,000 • 58 year old female. Coronary artery bypass graft surgery complicated by renal failure, GI bleeding, deep sternal infection (NEVER EVENT). Total Charges $1.0 million. Settlement Payment $400,000.00. Savings of $600,000

16. Questions Shawn Evans CEO Avandé 415-465-2534 sevans@avande.net