A thorough Out-of-Network billing process that is rooted in federal law helps providers to deliver the best patient outcomes while helping patients to utilize their insurance benefits.

Contego Solutions achieves both of these goals (delivering the best patient outcomes and ensuring patients can utilize the benefits they have paid for) through a two-pronged approach. Contego President, Liam Hughes, calls this “the science of the clean claim submission and the art of the appeal.” The claims process requires a dedicated team focused on the details (the science). The appeals process needs people who can piece data together in a coherent, cogent narrative that inspires a reimbursement event (the art).

In a perfect world, if you have a system of out-of-network claims and appeals built upon ERISA (Employee Retirement Income Security Act 1974) and PPACA (Patient Protection Affordable Care Act 2010), this would be all you need. In the real world, however, this is not usually the case. The only thing that can hold insurance carriers accountable is the federal law.

Contego has tracked shifts in the marketplace over the past couple of years. The PPACA permits carriers to link out-of-network reimbursements to Medicare rates. Contego’s President describes the situation this way. “Billing solutions really get down to understanding PPACA and self-employed groups’ ability to reduce, diminish, or prohibit benefits and to proactively vet for that. The game has changed a little bit, but there’s still huge opportunity out there.”

Since this is Contego’s specialty and this what we focus on every day, we notice even subtle changes. Summary plan document language has shifted. As you may know, plan administrators are required to provide participants with the Summary Plan Descriptions (SPDs), which is an overview of what a plan provides and how it works. Before the PPACA, providers had a legal right to access patients’ SPDs. Since adoption of the PPACA, only the patient or the patient’s advocate has the legal right to receive SPDs.


To effectively deal with those changes, Contego recommends employing an internal legal team to interact directly with plan administrators. Contego takes our own medicine. Our legal team’s work with plan administrators is a vital part of the process. Proactively obtaining the SPD as the patient’s legal advocate can be a lot of work, but it pays off because it enables everyone to know, before the surgery, how the plan is going to pay. 


Contego started proactively requesting the SPD at the beginning of 2018. It took about eight days to acquire the SPD after reaching out to the patient. Today, Contego can complete the process, from SPD obtainment to the financial estimate, in about four days. Liam sums it up well, “It’s really about alignment and about getting the systems in place to do it. We put this plan in place with providers that we work with, with amazing success.”