AMPS SERVICES. High-Dollar Claims Reviews and Audits: Out of Network Claim Review and Re-Pricing. Claim Benchmarking and Adjustments

Transcription

1

2 AMPS SERVICES High-Dollar Claims Reviews and Audits: AMPS utilizes proprietary software and physician reviewers to audit and confirm the accuracy and legitimacy of large hospital bills. AMPS has found, and the federal government has confirmed, that almost all hospital bills have errors and mistakes that typically increase costs for employers and their members. AMPS physicians review itemized statements and when necessary medical records on a line-by-line basis and correct mistakes, errors, fraud, waste, and abusive charges with an average outcome of a 6% reduction in payable billed charges. Out of Network Claim Review and Re-Pricing AMPS re-prices out of network hospital claims by first scrubbing the claim for clinical errors as well as mistakes, fraud, waste, and abuse and then applies a re-pricing methodology relative to agreed upon Reference Based Reimbursement levels. The outcome is typically client savings that is more than twice what the average OON service provider offers. Our service has almost no reversals and our internal advocacy team assists the member-provider negotiation when necessary regarding balance billing of either due or non-due funds. AMPS average adjustment on OON claims is 62% off of billed charges. Claim Benchmarking and Adjustments In addition to the review/audit of claims for errors, fraud, waste, and abuse, AMPS takes all received claims and benchmarks both billed charges and proposed payment levels to Medicare using an adjustment calculator to confirm reasonableness of fees for the provider and payer alike. If a client allows AMPS to substitute our suggested payment level for a network claim our clients typically see savings on average of 16% above and beyond the PPO discounted level. Reference Based Reimbursement PPO Replacement Programs AMPS and Claims Delegate Services (CDS) service offering for PPO disintermediation is by far the most sophisticated program available and is intended to stand the test of time as the long term replacement for the non-value PPO options. Our service starts with a very detailed analysis of current net payment levels and a through education about key program elements to all members of an employer sponsored plan. Education consists of printed and video materials that not only detail how the program works but explain 1 AMPS SERVICES

3 why such a service is necessary and the value created for the employer and member alike. in a competitive market we have a good opportunity to have the providers in that market compete for the employers business. AMPS legal team assists in the editing and development of new language that brings an employers summary plan description (SPD) into compliance with applicable standards as necessary to satisfy relevant fiduciary duties. CDS itself acts as co-fiduciary with plan sponsors to relieve most of the financial decision making burden from employers. CDS internally trained and managed member advocates work proactively with plan members to deal with collection or balance billing initiatives that may be undertaken by a provider. AMPS internal and external legal resources are deployed as needed on behalf of the plan, it s members, and ancillary service providers to the plan. AMPS/CDS goal is a billing resolution or settlement with providers that adequately and fairly pays for services rendered. AMPS Reference Based Reimbursement program typically reduces facility reimbursements by 40% relative to BUCA owned PPOs and over 60% relative to rental PPO networks. Narrow Networks / Direct Contracting AMPS utilizes direct contracting and narrow networks to reduce the noise factor of Reference Based Reimbursement (RBR). If an employer has a significant number of employee health plan members To determine which facility provider (hospital) to approach we take a historical usage pattern to determine overall market spending and to determine if any specific provider has an advantage. Unless advised differently by our payer/client, we would typically approach the most utilized provider first and offer them and their affiliate doctors the opportunity to direct contract and become the Tier One affiliate in that market. Tier One providers are singled out in the plan of benefits as the favored providers within that market and employers will promote their use by reducing co-pays and deductibles to create steerage. This reverses a 10+ year trend of health plans reducing corporate costs by shifting responsibility to members who most often can t afford the out of pocket exposure thus leaving hospitals with little option but to finance the out of pocket over a long term basis or write it off all together. This makes direct contracting very lucrative for the provider and allows them to offer favored reimbursement status to our employer client. As we aggregate direct contract relationships around the country we will naturally build our own centers of excellence hospitals allowing us to entice health plan members in more rural markets to have high quality discounted facilities to use as travel targets again reducing noise in the early stages of RBR deployment. AMPS SERVICES 4

4 Balance Billing Advocacy and Defense The AMPS / Claims Delegate Services, LLC ( CDS ) employee advocacy program provides assistance if a Company s health plan pays less than the full amount of a hospital claim because of charges that are found to be invalid or excessive, and then the hospital bills an employee for the amount the Plan did not pay. Of course, a hospital bill sent to an employee may include normal and valid charges that are an employee s responsibility to pay, such as deductible, co-pay or coinsurance amounts or fees charged for services that a Plan simply does not cover (e.g., elective cosmetic surgery). However, balance bills often include amounts that a Plan did not pay because the bill included errors or charges that were determined to be duplicative, invalid, impermissible or just plain unreasonable or excessive. Those are charges that your employee shouldn t have to pay. For most employees, balance bills are confusing, scary, and nearly impossible to deal with effectively. With AMPS/CDS as part of a health benefits team, employees will never have to handle Balance Bills alone because we will be there to help guide and protect them. When an employees receives a balance bill from a hospital, all they need to do is contact CDS to talk with a Billing Advocate, who will have ready access to a copy of an employee s claim records (i.e., the UB, Itemized Bill and Medical Bill Review report from AMPS) and will be able to start helping immediately. If an employee has a hospital bill that is audited by AMPS, a Billing Advocate will proactively call that employee once the claim is processed to personally introduce themselves, and to remind the employee that CDS advocates are there to help in case they do happen to get a Balance Bill. Billing Advocates are specially trained and deal with balance bill issues every day, and when one of your employees is balanced billed by a hospital and calls CDS, those Billing Advocates will be able to: Explain how a hospital claim was paid; Answer questions about Balance Billing; Help employees understand what portions of a Balance Bill are valid, and need to be paid as soon as possible, and what portions they should not have to pay and can legitimately dispute; Make employees aware of their rights; and Assist employees by stepping in and dealing with hospital billing and collection activity for them. AMPS/CDS has an in-house legal staff, and also keeps nationally recognized outside counsel on retainer to assist with resolving balance bill disputes, but it may still be desirable for an employee to have local counsel of their own. If necessary, CDS will help find and prepare an attorney to protect an employee against charges he or she should not have to pay. To facilitate locating and 5 AMPS SERVICES

5 engaging such local counsel, AMPS/CDS includes Legal Club of America Memberships in its programs for all plan participants (a $15 PEPM retail value with a typical wholesale price to employers of $11-12 PEPM). Plan attorneys will help Members represent themselves in small claims court Assistance in solving problems with government programs, such as INS and welfare AMPS/CDS - Legal Club of America Services Cooperative Services The following nine (9) services are available at no charge from your AMPS/CDS sponsored Legal Club of America plan attorney: Initial phone and face-to-face consultations for each new legal matter (no time limit) Review of independent legal documents (6 page maximum per document, no limit to the number of new independent documents) When deemed appropriate by a plan attorney, he or she will write initial letters on members behalf (one letter per legal matter, with no limit on the number of new legal matters) When deemed appropriate by a plan attorney, he or she will make initial phone calls on a member s behalf (one call per legal matter, with no limit on the number of new legal matters) There are also eight (8) commonly used legal services for which plan attorneys have agreed to charge a one-time, deeply discounted fee (court costs and filing fees additional). Members obtain legal referrals by contacting our Employee Advocacy Department, using the toll-free number provided above. There is no limit to the number of referrals a member may receive. Plan attorneys will prepare a free Simple Will for employees and their family, and update the Will annually. A state specific, web based, free Living Will form is available to Members. This form can be taken to a plan attorney and completed by the attorney for free AMPS SERVICES 8

6