Out of Network and Facility/Lab/Diagnostics
Your employer has partnered with Advanced Medical Pricing Solutions (AMPS) to help combat rising
healthcare costs by paying hospitals what is fair and reasonable for healthcare services, that is known
as Reference Based Reimbursement (RBR).
AMPS is a 3rd party re-pricer that works directly with your plan and TPA Maestro Health. Please read below for information regarding how AMPS helps you and the plan save money. Watch the video below for more information!
Hospital / Facility /Diagnostic / LAB
If you are in the 10-12% of employees that will visit a hospital or facility, you are free to visit any hospital and are no longer bound by the restrictions of “In-Network” or “Out-of-Network”.
When you visit a facility or hospital:
∙ The claim will be audited and fairly-priced by removing errors and determining what is a fair market value
∙ Patient Advocates will be notified and reach out to you to remind you to compare your Explanation of Benefits.
Compare Your Explanation of Benefits
Once you receive your Explanation of Benefits (EOB) from your Plan Administrator, always compare your “Employee’s responsibility” portion, to what your hospital bill states is due.
For example, your EOB is stating you owe $135, however when you review the hospital bill it states that you owe $4,817. This is what is known as a “Balance Bill”.
If you receive a balance bill or are contacted for additional payments, immediately contact your Patient Advocate at (800)425-9373.
A provider is stating that they do not accept my insurance, what do I do?
It is likely that they do not recognize the logo on the ID card. Explain that you have health benefits and request that they call your Plan Administrator to verify your benefits – the number is on your card. If you are still having difficulties, call your Plan Administrator for assistance.
Could the provider ask me to pay for my procedure upfront?
The provider performing your medical procedure may request money from you upfront however you as the patient are only responsible for your co-pay, co-insurance, and deductible. To confirm this dollar amount, contact your Plan Administrator. You can also refer to your Employee Benefit Booklet in the schedule of benefits. The only out-of-pocket you should pay upfront is your co-pay. Your deductible and co-insurance are determined once the hospital has sent their bill to your Plan Administrator. This amount will be listed on your Explanation of Benefits.
What if the provider asks me to pay more than my out-of-pocket?
Your benefits plan does not require you to pay anything upfront outside of your copay, co-insurance, or deductible. If the provider will not perform your treatment without money paid upfront outside of your personal responsibility, contact your Plan Administrator immediately and have an your Plan Administrator representative speak to the provider.
What should I do if I get a Balance Bill?
Contact AMPS immediately at (888)641-8834. Be prepared to send a copy of the front and back of the hospital statement to your Advocate. Once the invalid balance is verified, your Advocate will send you a Balance Bill Kit.
What is a Balance Bill kit?
A Balance Bill kit includes an Authorization Letter, Telephone Call Information Form, the Formal Notice Regarding Billing Errors and Dispute of Charges, and the Collection Agency Rules List. The Authorization and the Formal Notice should be signed and returned to AMPS as soon as possible.
Once notified of the dispute, will the provider stop sending bills?
You will probably continue to get a statement from the provider every month. Providers are large and their billing is automated, so it's very difficult for them to interrupt a single statement.
Can I ask a provider or their representative to contact AMPS instead of calling me?
Yes, you can. If you receive a call about charges that have been disputed, you can ask them to contact AMPS at (888)641-8834. Tell the caller that you have appointed AMPS as your Authorized Representative.
How long does it take to resolve an invalid Balance Bill with the provider?
It can be a lengthy process. Even working within the federal guidelines, it can take several months to resolve an invalid balance.
What if I need additional treatment at this hospital/surgery center? Will they turn me away?
It has not been AMPS experience to have a provider turn away a member due to balance billing. If you encounter any admissions issues, please call your Plan Administrator right away so that AMPS and your Plan Administrator can work together to resolve the issue.
If you receive a balance bill, please contact AMPS immediately at (800) 425-9373. Be prepared to send a copy of the front and back of the hospital statement to your Patient Advocate. Once the invalid balance is verified, your Patient Advocate will send you a Balance Bill Kit.
If you can’t pay the patient responsibility as shown on your EOB, set up a payment arrangement. Do not sign anything saying you’ll pay more than the patient responsibility. Failure to make timely payments consistently will limit your Patient Advocate’s ability to protect you against balance billing and may even expose you to additional financial liability.
Have You Received A Balance Bill?
Balance Bill: a statement from a hospital or facility claiming a higher balance than what the original Explanation of Benefits (EOB) says was owed.
What Happens After Healthcare Visit
After you visit a professional’s office or facility, the provider will create an invoice for healthcare services (this is called a claim).Your claim is then sent to Maestro Health and AMPS for processing and payment. Maestro Health validates coverage and AMPS checks each claim using a physician review process and then prices the claim using a reference based reimbursement approach which results in more reasonable charges. AMPS analyzes over a decade of claims data when reviewing claims, which is combined with repricing acceptance rates for providers across 50 states. Maestro Health will then send payment to the provider with an explanation of the review if needed.
REVIEW AND PAYMENT
After spotting your claim when it flows through AMPS review process, AMPS Advocates will contact and remind you they stand ready to help should you receive any additional request for payment from the provider.
In most cases the provider accepts the payment from Maestro Health. However, there are some providers with accounting systems configured to automatically generate balance bills to patients if they received a payment for less than the initial billed charges. Some providers may contact you for collections. If you happen to receive a bill for the balance of remaining amount (called a “balance bill”) or a collections letter/call, contact AMPS immediately at (888)641-8834 and your Advocacy Team will assist.
Once AMPS is notified of a balance bill or collections attempt, an Advocate Authorization form will be sent to you for signature which allows AMPS Advocates to speak directly with the provider regarding the benefit plan, payment determination and optional appeal process. AMPS will keep you updated on communications with the provider and answer any of your questions that may arise.
In most cases the provider accepts payment after speaking with your Advocate, however as a fiduciary for your benefit plan, providers may appeal directly to AMPS for additional payment. AMPS will review and may adjust the payment if the provider presents additional information to warrant added payment. Alternatively, the provider may balance bill again for the denied charges.
Most important, and most difficult, is to stand firm. The length of time it takes to reach resolution will be dependent on the specifics of your claim. Being told you owe money can be frustrating and creates anxiety. Know the provider received fair and reasonable payment for your claim. Remember provider bills are automatically generated - you may even receive one while your Plan Administrator and AMPS are disputing the additional changes on the balance bill.
PROVIDER OVERCHARGE DEFENSE
Should the provider attempt legal recourse to collect invalid balances, AMPS Defense Team will defend balance bills and any litigation, at no cost to you, until full resolution.
* See full benefit summaries for details, exclusions, out of network information, & other coverage. Covered expenses only. This web site is not a legal document. This web site is not a guarantee of coverage, eligibility, or provider status and is designed for informational illustration only. Benefits outlined on this web site are subject to change at any time. Please consult your benefit plan provider(s) or administrator(s) for legal documents regarding your plan and to check coverage and/or eligibility