Uncovering Healthcare Profitability

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Why would I want to go Out-of-Network ?

Out-of-Network surgical centers have much lower infection rates than hospitals. The selected Out-of-Network surgery center allows physicians to use top of the line products that maximize patient outcomes as well as produce faster recovery times.

Is going Out-of-Network going to cost the patient more money ?

It depends on your insurance plan as AllianceMed does not dictate costs. However, we will work with the provider to see what the patients personal finances will allow for them to pay.

How does the patient know if they have Out-of-Network Benefits ?

AllianceMed checks the benefits of all their patients to ensure they have the correct benefits before surgery is scheduled. By verifying the patients Out-of-Network benefits, AllianceMed can help limit out of pocket costs.

Wouldn’t the patient receive the same care at an in-Network facility ?

The main reason the doctor choses a particular facility over any other is because they want to be able to use the best products, in the highest quality setting available for the patients surgery, thus providing a maximum level of care for the patient.

How does using DME or Implants help doctors absorb deductibles ?

The first bill that hits the insurance company will be the first one applied to the deductible, if the insurance company determines that it is a covered benefit. By utilizing AllianceMed, they can ensure that the DME claim goes out before the professional or facility claims go out, this gives the provider the best chance of absorbing deductibles and making each event that follows a profitable event.

Who will submit the Facility or Physician In Network claims ?

AllianceMed specializes in Out-of-Network claims submission but has the ability to submit claims In-Network when needed. Ideally the provider will continue to use the current billing for in-network claims.

Why submit claims on paper ? Is this not an antiquated process ?

Insurance carriers likes to have providers submit claims electronically because it is a simple process for both parties, yet Out-of-Network policies require that the claim should be submitted as a hard copy. When submitting a hard copy the Facility or Physician is able to submit all supporting documents (Op reports, medical necessity, etc) that will increase the likelihood of the claims getting processed correctly and efficiently.

What is Recoupment/Overpayment ?

An overpayment is an attempt by the TPA to recover money that was previously paid out to the medical provider for services rendered. Insurance company obtains recoupment from the provider by withholding future payments form other patients.

Why did the facility or physician bill the patient’s insurance company so much for the procedure/device ?

They bill the same way hospitals do, and the bills are high because they use the top of the line equipment to ensure the patients speedy recovery.

Is it legal for the Facility or Physician to bill such a high amount for the procedures/devices ?

Prior to any claims being billed through AllianceMed Titan Billing Process, all rates will be agreed upon with AllianceMed Rate Addendum Agreements to ensure that both parties agree that these rates are reasonable for the services provided. AllianceMed has in-house attorneys who review these claims to ensure that everything is above board throughout the entire process.