In & Out-of-Network Health Benefits

Arizona-based Advanced Reimbursement Solutions works with healthcare providers and insurers to see that patients receive the benefits they pay for. Advanced Reimbursement Solutions specializes in the administration of out-of-network ("OON") medical claims and health plans.

The primary difference between in-network and OON benefits is that medical providers that are in-network have entered a contractual agreement stipulating the types of medical procedures covered by the insurance company and the rate at which they are permitted to bill those procedures. OON medical providers have not entered a contractual agreement with the insurance company, and far fewer restrictions exist regarding the types of procedures and rates at which they are reimbursed by the insurance carrier.

When a physician or other healthcare provider agrees to become part of a network, the provider and the insurance company settle on a price for services. If a patient sees an in-network physician, the cost is covered by the patient’s insurance plan (and the patient, if there is a co-pay). However, if the physician is not in the network, the patient may have to pay all of the cost.

The two basic types of care plans are the HMO and the PPO. The Health Maintenance Organization (HMO) limits patients to physicians who belong to a network, while a Preferred Provider Organization (PPO) allows patients to choose their physicians, regardless of whether they are in or out of the network. While the PPO may sound more attractive, insurance premiums for the patient are typically higher, so there can be a “price” for the flexibility the patient enjoys.

Advanced Reimbursement Solutions is driven by decades of data and unique experience in ensuring that OON benefits are administered and adjudicated appropriately by insurance carriers. ARS works to advocate for the patient so they are able to receive the care they need at an affordable cost.

Surprise Billing Legislation Passes

Advanced Reimbursement Solutions assists patients and physicians with medical billing reimbursements. As part of its corporate mission, Advanced Reimbursement Solutions advocates for pro-patient, pro-physician healthcare reform. Legislators addressed one area of healthcare reform by passing a law related to surprise billing in December 2020.

Surprise billing occurs when a medical provider sends a bill to a patient for a service that the patient thought would be covered by insurance. This can leave a patient with a significant amount of debt. For example, a patient may use an in-network facility but receive care from an out-of-network provider (i.e., an anesthesiologist). If the out-of-network provider cannot collect the full amount of care from the insurer, the patient is billed directly.

A nationwide ban on surprise billing passed as part of a COVID-19 relief package. Providers will now have to contact insurers to work out payment. The new law will not take effect until 2022 and applies to air ambulances (not ground), hospitals, and doctors.

Advanced Reimbursement Solutions holds insurance carriers accountable to appropriately administer the benefits patients pay for, and communicate with them directly on behalf of healthcare providers and patients. Through their proprietary redetermination process, understanding of applicable state and federal law, and negotiation processes, providers and patients are alleviated of the administrative burden, and able to focus on better medical treatment.