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Healthcare Shopping Basics

Healthcare Services

After you visit a professional’s office or facility, the provider will create an invoice for healthcare services (this is called a claim).

 

Review and Payment

Your claim is then sent to Your Plan Administrator and AMPS for processing and payment. Your Plan Administrator 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. Your Plan Administrator will then send payment to the provider with an explanation of the review if needed.

 

Member Outreach

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.

A Balance Bill/Collections Letter

In most cases the provider accepts the payment from Your Plan Administrator. 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 (800)425-9373 and your Advocacy Team will assist.

 

Member Advocacy

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.

 

Appeal Process

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.

 

Stand Firm

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.

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