Out-of-Network Solutions

OON

OON Repricing Service

Out-of-Network claims (OON) typically represent about 7% to 8% of an employer's health plan costs. OON claims generally occur when a member is traveling and requires high cost urgent or emergency care, but also occur locally when a member seeks care outside their PPO network.

AMPS auditing process typically cut the employer’s total OON costs by at least 30%. AMPS’ rigorous process melds Medical Bill Review and Reference Based Reimbursement processes to come up with the quintessential OON repricing service. AMPS audits all claims, particularly hospital invoices, to make sure everything is clinically accurate and mistake free, then applies Reference Based Pricing data points to all claims to reach a fair and reasonable price reimbursed to providers with the employer’s money. AMPS OON process can average 68-72% discount off billed charges and usually doubles the savings most employers get from their current OON repricing vendor.



What About Wrap Networks?

1

Many vendors provide OON claims management using wrap networks. The flaw with most wrap networks is they are based on existing PPO “discounts” as their baseline. Most of those equate to about a 20-30% discount off billed charges, but any discount off a grossly overbilled charge doesn't really yield much savings.

2

It’s a generally known fact OON is a cash-cow for the BUCAs (Blue, United, Cigna, Aetna), providing minimal discounts, typically through a wrap network, that charges huge fees (30% to 35% of savings). BUCAs often make more money managing employers’ 5% of OON claims than they do managing the 95% of claims that are in-network.

AMPS OON service, using a combination of MBR audits and RBR repricing services, typically doubles the employer’s OON savings with a more modest service fee.

Still Have Questions? Contact an AMPS Client Representative