Last month in this space, we analyzed a few of the potential pitfalls of signing a discount contract with Align Networks. Align has been subject to controversy lately – first, with its questionable instruction to prematurely bill unadopted Medicare codes, and then again when the Independent Physical Therapists of California (iPTCA) took them to court alleging fraudulent and illegal behavior. Today, we take a closer look at an Align discount contract and explain why its discounted payment is applicable even when Align does not refer the patient for treatment.

Upon signing the Align Network Participating Provider Agreement, many providers assume that the steeply discounted reimbursements to which they agree apply only to specifically designated services – and only to services where the provider received a direct referral from Align Networks. To be fair, that seems to be a reasonable assumption.

Unfortunately, an Align Networks Participating Provider Agreement reviewed by DaisyBill clearly establishes that the Align discounted reimbursement can apply to all injured employees for all services provided, even when Align did not directly refer the patient to the provider.

Once again, we turn to recent customer support cases fielded by our support team to better explain the issue at hand. The two support cases below were submitted in the last two months, and both have been lightly edited for clarity.

March 2017

Gallagher Bassett is denying a routine Office Visit rendered by the approved primary treater. They are requesting that we send bills to Align Networks for Payment. 

May 2017
I billed a patient’s account for a PR2. The insurance is Gallagher Bassett, but we received payment from Align Networks. I called Align, and they said that the bill was sent to them from the insurance. But we only billed Gallagher Bassett. Is there anything I can do to ensure that Gallagher doesn’t send our money to Align? We’re only contracted with Align for PT and Chiro, not PR1 and PR2 visits. It creates a lot of work for us to try and recuperate the additional money owed. I called Align and they will not pay us the difference.

Our clients are confused because they didn’t read the fine print in their Participating Provider Agreement, which allows Align Networks to apply the steep discounted reimbursement to any and all services. Below, we reference some of the contract language which would allow Gallagher Bassett to use the Align discount as noted in the the above support cases.

The Definitions section of the Participating Provider Agreement establishes that, when Align is contracted with the payer responsible for the injured employee, all “Covered Services” provided to an injured employee are subject to the terms of the contracted reimbursement discount. The Participating Provider Agreement does not limit the “Covered Services” to specific services. Instead, the Agreement allows for any and all services that are generally and customarily provided to patients (emphasis ours):

“‘Covered Services’ shall mean those Medically Necessary services including, but not limited to physical and occupational therapy, aquatic therapy, work hardening, and functional capacity evaluations, which are generally and customarily provided to patients.”^[1]

The discount Align contract available on the iPTCA website includes an Exhibit A, titled “ALIGN Pricing Schedule - State of California.”^[2] A careful review of this Exhibit reveals that Align limited the amount of reimbursement to $55 per day, but excluded some “Carve Out Codes” which do not apply to the maximum daily reimbursement. This Exhibit also seems to allow for a blanket application of the Align contract and steep discount to all procedures.

Per Exhibit A, Align Networks will reimburse for initial evaluations “at the lesser of 70% of the applicable workers compensation fee schedule or 100% of Participating Provider's billed charges for the Initial Evaluations (CPT Codes 97001 & 97003). Initial evaluations excluded from daily maximum reimbursement.”

For daily maximums, “Align Networks will reimburse at the lesser of 70% of the applicable workers compensation fee schedule, up to a maximum of $55 per daily visit/session or 100% of Participating Provider’s billed charges.”

Finally, “all other procedures billed and not listed above will be reimbursed at 30% off applicable Workers’ Compensation state fee schedule or agreed upon rates.”

What does it all mean? Even if Align does not refer the patient to the provider, the Align contract and discounted reimbursement can apply to services rendered when the bill review entity chooses to apply the leased Align contract.

It’s yet another reason to exercise extreme caution when entering into a discount contract – with Align or any other network. And never ignore the fine print.

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