Advanced, Quality, Medical Reviews

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.

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. Why Avandé?

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.

Advanced, Quality, Medical Reviews

THE PROBLEM Healthcare 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)

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

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

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

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

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

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)

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)

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

A Few Success Stories

Questions Shawn Evans CEO Avandé