Science of the Clean Claim Submission, the Art of the Appeal, and Federal Law

The Employee Retirement Income Security Act of 1974 (ERISA) offered providers a clear path for success in the out-of-network claims and appeals process. In 2010, PPACA fortified patient protections and added process complexity.

Unfortunately, most healthcare providers are expected to do more work than they did last year, with increased administrative burden, and expect less financial return. Most independent providers don’t have the depth and breadth of knowledge, background, experience or resources to make the out-of-network play still work for them financially.

That’s the work of Contego Solutions. Contego is expert in all the phases of the out-of-network claims and appeals process, so providers can deliver the best patient outcomes. Contego helps patients utilize their insurance benefits, so they receive the care they need and have paid for and providers are reimbursed.

Contego’s work relies on the science of the clean claim submission and the art of the appeal. The process requires a dedicated team focused on the details. Contego’s staff are trained and skilled in piecing data together in coherent, cogent narratives that along with attention to the legally prescribed process inspire reimbursements.

Contego’s President, Liam Hughes says of the process, “In a perfect world, if you have a system of out-of-network claims and appeals that’s built on ERISA and PPACA, that’s all you need. But that’s not usually how it plays out. The only thing that can hold insurance carriers accountable to fulfilling their responsibility is the federal law.”