Preferred Provider Organization (PPO) Anthem Blue Cross is enabling egregious abuse of California providers at scale.

Since June, dozens of claims administrators have improperly gutted a California orthopedic practice’s reimbursements by misapplying an Anthem PPO contract—reducing the practice’s revenue to far below Medicare rates across hundreds of bills.

The orthopedic practice signed a crystal-clear agreement with Anthem to accept 95% of the California Official Medical Fee Schedule (OMFS) rates for treating injured workers. Inexplicably, claims administrators have slashed reimbursements to as low as 42% of OMFS rates.

Providers are not defenseless against this Anthem carnage—and soon, daisyBill will reveal how we plan to help. Until then, we urge all California providers contracted with Anthem to:

1. Save Explanations of Review (EORs) that report Anthem contractual discounts
2. Obtain your Anthem agreement to review the contractual reimbursement rates

Providers desperately need protection from a state that has all but abandoned them—and daisyBill is going to help.

Read on to see the details of this unconscionable provider exploitation, brought to you by Anthem.

Anthem PPO Enables Serious Provider Abuse

Per the Anthem PPO contract the orthopedists signed, when Anthem leases/sells/transfers the contractual discount to various payers, the provider receives reimbursement at the lesser of three options:

• 95% OMFS
• The provider’s billed charges
• “Bill Review Allowed”

Neither the Bill Review Allowed nor the provider’s billed charges are less than 100% of OMFS rates, which leaves only one option: to pay the doctors at 95% OMFS. 

Instead, the doctors have received hundreds of EORs like the ones below, in which claims administrators cite the Anthem contract to grant themselves PPO discounts far in excess of the contractual terms.

Below are three examples demonstrating that rather than reducing the orthopedists bills by 5%, these claims administrators discounted the bills by over 50%. In each instance, the reductions were more than the amounts the claims administrators paid the doctor:

• State Compensation Insurance Fund paid 42% OMFS (63% Medicare)
• Liberty Mutual paid 46% OMFS (69% Medicare)
• ESIS paid 42% OMFS (63% Medicare)

Providers cannot financially sustainably treat injured workers at these rates. By failing to protect providers, California is asking them to treat injured workers at a loss.

What Recourse Do Providers Have?

Worst of all, providers currently have no feasible way to stop this abuse. 

Since the California Division of Workers’ Compensation (CA DWC) has repeatedly declared disputes over PPO contract abuse ineligible for Independent Bill Review, providers cannot rely on the appeals process to get correct reimbursement. So what’s a provider to do?

According to this orthopedic group’s experience, the only options are:

1. Hire a team of attorneys to fight Anthem and 24 deep-pocketed claims administrators, or
2. Walk away from workers’ comp entirely

However, daisyBill will soon publish steps providers can take to determine the precise amount of reimbursement their Anthem PPO contract is gouging from their practices, and some options for next steps.

Who Will Stop the PPO Predators?

Anthem’s misconduct isn’t an isolated event. It’s emblematic of California workers’ comp in 2025—a broken system where providers are prey and regulators look the other way.

In multiple cases, the CA DWC continues to shrug while payers abuse and violate PPO contracts.

The state is failing doctors, but the consequences will fall hardest on employers and employees. California must decide: will it protect injured workers’ access to care—or let PPO profiteers slowly dismantle the system?

Below is a complete list of the 24 claims administrators who improperly cut this practice’s revenue using the Anthem PPO contract since June 2025.

Get a window into exactly how payers use PPOs to (often improperly) slash your practice revenue with daisyBill.

LEARN MORE: DAISYBILL