John Powers | Advanced Medical Pricing Solutions

Reconstructing Healthcare: Innovative Solutions For Employers To Lower Their Healthcare Costs

In this episode, Michael introduces John Powers, the Executive Vice President of Sales and Marketing for Advanced Medical Pricing Solutions (AMPS). AMPS provides market-leading healthcare cost containment services for self-funded employers, public entities, municipalities, labor unions, brokers, consultants, TPAs, payers, reinsurers, and HMOs. John is widely known as one of the most successful fraud investigators in the industry having conducted investigations in all 50 states and over 120 countries internationally.

John dove into the healthcare industry about 12 years ago when he saw problems arising within the system. He found that many people held a misconception about their healthcare plans by thinking their plan covers everything when, in fact, it likely doesn’t. John believes consumerism is the missing link in our healthcare model, and he predicts a future where more employers move to a model of defined benefits. This, he believes, will make the system more equitable and transparent.

Among other services, AMPS conducts medical bill reviews. They focus on hospital and facility claims, both inpatient and outpatient, that are in or out of the network. This line-by-line itemized review by coding specialists ensures that the correct treatment was done at the right time and for the right price - and their turnaround is only an average of 3.3 days.

The problem is that most claim payers (TPA’s, Insurance Carriers) don’t get itemized facility bills, so they never get the chance to review them for errors and see where they’re being incorrectly charged. To complicate matters further, some health plans aren’t even requiring itemized Hospital bills prior to paying them. John speculates that this is because healthcare companies see hospitals as their most valuable asset.

Shockingly, errors on hospital bills are extremely common, and 95% of the time they go unnoticed. AMPS uncovers errors in virtually 100% of bills ranging from $2 to $200,000, and most of their clients see an average of 10% in savings. And since AMPS only gets paid from the savings they find, there’s no upfront cost to using their service. The errors are corrected before the client pays the bill, as it’s notoriously difficult to request a refund after payment has already been rendered.

John insists that if employers want to get control of their medical spend, they must unbundle the health plan components and get away from the limitations imposed by traditional insurance carriers. That way, they can review and audit their claims just as they would any other facet of their company’s budget.

To prove why medical bill review is so important, John suggests asking your carrier account manager these three fundamental questions:

1. Are you conducting a prepayment facility medical bill review for us, and if so, at what threshold and what are the results? How many errors have you found?
2. Are you a fiduciary to my plan?
3. Please confirm what network discount I am getting and what does that equate to as a percentage of Medicare?

John is confident their response will surprise and disappoint you, as they likely aren’t conducting a prepayment medical bill review, aren’t a fiduciary, and aren’t giving you the savings you thought.

AMPS provides other services, like a reference-based pricing program that they’ve offered for the past 8 years. There are two models: Prospective, which negotiates on the front end but costs more, and retrospective, where negotiation is after the service and there are greater savings. They also do direct contracting. This is where consumerism and competition come into play to benefit both the hospital and employer.

AMPS is excited to offer more direct contracts so patients can save money, know their options, get great care, and make informed decisions. The medical bill review process - and the other services that AMPS has to offer - are for any industry. Overpayment in the healthcare industry needs to end, and companies like AMPS are taking strides to make that possible.

Here’s a glance at what we discuss in this episode:

• 00:30 - Introducing John and the issues he sees in the healthcare industry
• 08:40 - The AMPS platform and the problem they solve
• 17:30 - Itemized bill restrictions and the average savings of medical bill review
• 22:00 - How AMPS integrates with the TPA and makes sure payment is accurate
• 31:00 - The other services that AMPS provides
• 41:00 - Exciting evolutions and the movement towards healthy competition
• 43:30 - The three fundamental questions to ask your carrier to prove their value

Resources

AMPS Website: https://advancedpricing.com/

John’s Email: [e-mail]

John’s Phone Number: [phone]