Anthem: PPO Discount Payments BELOW Medicare

May 19, 2021 22 min read

By: Catherine Montgomery

Anthem: PPO Discount Payments BELOW Medicare

Q: How much can a workers’ comp provider lose by signing a Preferred Provider Organization (PPO) agreement?

A: Much, much more than the provider probably realizes.

In many instances, PPO agreements result in providers receiving reimbursements substantially below the amount allowed by Medicare.

Below, data from a single physician demonstrates the exorbitant price of a PPO agreement, once the PPO leases the discount to various payers. Fair warning for the faint of heart: these numbers are staggering.

Anthem: Massive Revenue Reduction Below Medicare

Effective for dates of service on or after 3/1/2021, California increased the reimbursement for Evaluation and Management (E/M) services. Per the Official Medical Fee Schedule (OMFS), the reimbursement due to the provider for common E/M CPT code 99214 is $188.78.

Below, an Explanation of Review (EOR) from State Compensation Insurance Fund (SCIF) shows that rather than reimbursing the provider $188.78, SCIF instead remitted:

$97.27 to the provider (52% of the OMFS reimbursement) and
$91.51 to Anthem Blue Cross (48% of the OMFS reimbursement)

Important: In the above example, SCIF reimbursed the provider substantially less than Medicare would for the same procedure code, CPT 99214. Specifically, this provider received a reimbursement 32% LOWER than the $143.61 reimbursement amount allowed by Medicare.

Repeatedly, we ask:

Why does the California workers’ comp system enrich Anthem Blue Cross in this manner?
Is Anthem ‘sharing’ the revenue taken from the provider with SCIF in some way?

More Bad News for Providers (Great News for Anthem)

Regular readers of this blog know that network discounts, once agreed to by the provider, can be leased, sold, or otherwise transferred to countless payers. But one look at just how liberally a discount can be spread around is shocking.

In the table below, we reveal the macro-effects. For a single provider, we tracked the percentage of OMFS reimbursement rates various claims administrators paid to the provider when the claims administrator cited Anthem as the reason for the discounted payments.

To better understand the table and Anthem’s impact on this provider, refer to this key:

Contract Name

Claims Administrator

% OMFS Paid

Bill Count

The Anthem discount agreement listed by the claims administrator on the EOR to justify reimbursement reductions

The insurer, TPA, or employer that applied the Anthem discount

Rather than 100% of OMFS reimbursement, the percentage of OMFS reimbursement actually paid to the provider after subtracting the Anthem discount

The number of EORs on which the Claims Administrator cited the Contract Name since February 2020

California OMFS reimbursement for treating injured workers is approximately 131% of the reimbursement allowed by Medicare. But where the ‘% OMFS Paid’ is below 69%, the provider received less than the amount allowed by Medicare.

Strap in and prepare to grasp the sheer scale of Anthem’s impact on this single provider. And again, ask yourself: Why are California workers’ comp providers enriching Anthem at providers’ expense?

Contract Name	Claims Administrator	% OMFS Paid	Bill Count
Anthem PPO Contract	State Compensation Insurance Fund (CA)	69%	365
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	69%	230
Anthem Blue Cross	Insurance Company of the West	69%	209
Anthem Blue Cross	Keenan & Associates	69%	113
Anthem Blue Cross	AmTrust North America	69%	78
Anthem PPO Contract	State Compensation Insurance Fund (CA)	53%	66
Anthem Blue Cross	Broadspire	69%	63
Anthem Blue Cross	City of Los Angeles (CA)	69%	61
Anthem Blue Cross	Keenan & Associates	59%	60
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	52%	57
Anthem PPO Contract	State Compensation Insurance Fund (CA)	72%	54
Anthem PPO Contract	State Compensation Insurance Fund (CA)	85%	52
Anthem Blue Cross	Insurance Company of the West	85%	49
Anthem Blue Cross	Insurance Company of the West	72%	47
Anthem PPO Contract	State Compensation Insurance Fund (CA)	58%	40
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	59%	38
Anthem Blue Cross	Insurance Company of the West	59%	35
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	72%	34
Anthem Blue Cross	Berkshire Hathaway Homestate Companies	69%	32
Anthem Blue Cross	Insurance Company of the West	53%	30
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	85%	30
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	56%	29
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	58%	29
Anthem PPO Contract	State Compensation Insurance Fund (CA)	52%	28
Anthem Blue Cross	Acclamation Insurance Management Services	69%	28
Anthem Blue Cross	Keenan & Associates	85%	27
Anthem Blue Cross	Keenan & Associates	62%	26
Anthem Blue Cross	Liberty Mutual Insurance	69%	26
Anthem Blue Cross	Insurance Company of the West	52%	25
Anthem Blue Cross	AmTrust North America	59%	25
Anthem Blue Cross	Tristar Risk Management	69%	25
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	75%	25
Anthem Blue Cross	Keenan & Associates	57%	24
Anthem Blue Cross	California Insurance Guarantee Association	69%	24
Anthem Blue Cross	Insurance Company of the West	58%	23
Anthem Blue Cross	City of Los Angeles Department of Water and Power (CA)	72%	22
Anthem Blue Cross	Keenan & Associates	52%	21
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	51%	20
Anthem Blue Cross	City of Los Angeles Department of Water and Power (CA)	53%	19
Anthem Blue Cross	Insurance Company of the West	62%	19
Anthem Blue Cross	Broadspire	59%	18
Anthem Blue Cross Pend and Transmit	Sedgwick Claims Management Services	69%	18
MPN-Anthem Blue Cross	Sedgwick Claims Management Services	69%	18
Anthem PPO Contract	State Compensation Insurance Fund (CA)	51%	17
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	53%	17
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	62%	17
Anthem Blue Cross	Acclamation Insurance Management Services	72%	17
Anthem Blue Cross	Keenan & Associates	72%	17
Anthem PPO Contract	State Compensation Insurance Fund (CA)	56%	16
Anthem PPO Contract	State Compensation Insurance Fund (CA)	62%	16
Anthem Blue Cross	Elite Claims Management	69%	15
Anthem Blue Cross	Tokio Marine Management	69%	15
Anthem Blue Cross	California Insurance Guarantee Association	72%	15
Anthem Blue Cross	Church Mutual Insurance Company	56%	13
Anthem Blue Cross	Acclamation Insurance Management Services	59%	13
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	60%	13
Anthem Blue Cross	City of Los Angeles (CA)	72%	13
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	60%	12
Anthem Blue Cross	AmTrust North America	85%	12
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	51%	11
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	72%	11
Anthem Blue Cross	Acclamation Insurance Management Services	85%	11
MPN-Anthem Blue Cross	Sedgwick Claims Management Services	85%	11
Anthem Blue Cross	Liberty Mutual Insurance	53%	10
Anthem PPO Contract	State Compensation Insurance Fund (CA)	54%	10
Anthem Blue Cross	Church Mutual Insurance Company	59%	10
Anthem Blue Cross	Elite Claims Management	59%	10
Anthem Blue Cross	AmTrust North America	62%	10
Anthem Blue Cross	Sedgwick Claims Management Services	69%	10
Anthem Blue Cross	AmTrust North America	72%	10
Anthem Blue Cross	Elite Claims Management	72%	10
Anthem Blue Cross	Keenan & Associates	48%	9
MPN-Anthem Blue Cross	Sedgwick Claims Management Services	49%	9
Anthem Blue Cross	Farmers Insurance	54%	9
Anthem Blue Cross	Liberty Mutual Insurance	56%	9
Anthem Premier MPN	Farmers Insurance	69%	9
Anthem Blue Cross	Broadspire	48%	8
Anthem PPO Contract	State Compensation Insurance Fund (CA)	48%	8
Anthem Blue Cross	Church Mutual Insurance Company	51%	8
Anthem Blue Cross	Insurance Company of the West	54%	8
Anthem Blue Cross	Church Mutual Insurance Company	69%	8
Anthem Blue Cross	Farmers Insurance	69%	8
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	69%	8
Anthem Blue Cross	Keenan & Associates	42%	7
Anthem Blue Cross	Broadspire	52%	7
Anthem Blue Cross	Pacific Compensation Insurance Company	52%	7
Anthem Blue Cross	Broadspire	58%	7
Anthem Blue Cross	Keenan & Associates	58%	7
MPN-Anthem Blue Cross	Sedgwick Claims Management Services	58%	7
Anthem PPO Contract	State Compensation Insurance Fund (CA)	59%	7
Anthem Blue Cross	Broadspire	62%	7
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	62%	7
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	68%	7
Anthem Blue Cross	Midwest Insurance	69%	7
Anthem Blue Cross Pend and Transmit	Sedgwick Claims Management Services	72%	7
Anthem Blue Cross	Church Mutual Insurance Company	85%	7
Anthem PPO Contract	State Compensation Insurance Fund (CA)	46%	6
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	50%	6
Anthem Blue Cross	Tristar Risk Management	59%	6
MPN-Anthem Blue Cross	Sedgwick Claims Management Services	62%	6
Anthem Blue Cross	Acclamation Insurance Management Services	63%	6
Anthem Blue Cross	Insurance Company of the West	70%	6
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	70%	6
Anthem Blue Cross	Sedgwick Claims Management Services	85%	6
Anthem Blue Cross	Liberty Mutual Insurance	48%	5
Anthem Blue Cross	State Compensation Insurance Fund (CA)	52%	5
MPN-Anthem Blue Cross	Sedgwick Claims Management Services	56%	5
MPN-Anthem Blue Cross	Sedgwick Claims Management Services	59%	5
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	61%	5
Anthem PPO Contract	State Compensation Insurance Fund (CA)	64%	5
Anthem Blue Cross	Acclamation Insurance Management Services	65%	5
Anthem Blue Cross	Insurance Company of the West	67%	5
Anthem PPO Contract	State Compensation Insurance Fund (CA)	68%	5
Anthem Blue Cross	City of Los Angeles Department of Water and Power (CA)	69%	5
Anthem PPO Contract	Liberty Mutual Insurance	69%	5
Anthem Blue Cross	Broadspire	72%	5
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	85%	5
Anthem Blue Cross	Tristar Risk Management	85%	5
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	44%	4
Anthem Blue Cross	Sedgwick Claims Management Services	49%	4
Anthem Blue Cross	Broadspire	51%	4
Anthem Blue Cross	Insurance Company of the West	51%	4
Anthem Blue Cross	AmTrust North America	52%	4
Anthem Blue Cross	Berkshire Hathaway Homestate Companies	53%	4
Anthem Blue Cross	Church Mutual Insurance Company	53%	4
Anthem Blue Cross	Broadspire	60%	4
Anthem Blue Cross	Elite Claims Management	62%	4
Anthem Blue Cross	Pacific Compensation Insurance Company	62%	4
Anthem Blue Cross	City of Los Angeles Department of Water and Power (CA)	63%	4
Anthem Blue Cross	Insurance Company of the West	63%	4
Anthem Blue Cross	Sempra Energy Employee Care Services	63%	4
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	67%	4
Anthem Blue Cross	Insurance Company of the West	68%	4
Anthem Worker's Comp	City of Torrance (CA)	69%	4
Anthem PPO Contract	State Compensation Insurance Fund (CA)	71%	4
Anthem Blue Cross	Farmers Insurance	72%	4
Anthem Blue Cross	Sempra Energy Employee Care Services	72%	4
Anthem Blue Cross	Tristar Risk Management	72%	4
MPN-Anthem Blue Cross	Sedgwick Claims Management Services	72%	4
Anthem Blue Cross	Insurance Company of the West	75%	4
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	75%	4
Anthem PPO Contract	State Compensation Insurance Fund (CA)	77%	4
Anthem Blue Cross	Farmers Insurance	82%	4
Anthem Blue Cross	Farmers Insurance	83%	4
Anthem Blue Cross	City of Los Angeles (CA)	85%	4
Anthem Blue Cross	Farmers Insurance	85%	4
Anthem Blue Cross	State Compensation Insurance Fund (CA)	85%	4
Anthem Blue Cross	Broadspire	21%	3
Anthem Blue Cross	Broadspire	44%	3
Anthem Blue Cross	AmTrust North America	45%	3
Anthem Premier MPN	Farmers Insurance	45%	3
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	50%	3
Anthem Blue Cross	Berkshire Hathaway Homestate Companies	52%	3
Anthem Blue Cross	Liberty Mutual Insurance	52%	3
Anthem Blue Cross	The Zenith	52%	3
Anthem Premier MPN	Farmers Insurance	52%	3
Anthem Blue Cross	Sedgwick Claims Management Services	53%	3
Anthem Blue Cross	Tokio Marine Management	54%	3
Anthem Premier MPN	Farmers Insurance	54%	3
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	56%	3
Anthem Blue Cross	AmTrust North America	58%	3
Anthem Blue Cross	Liberty Mutual Insurance	58%	3
Anthem Blue Cross	City of Los Angeles (CA)	59%	3
Anthem Blue Cross	Zurich Insurance North America	59%	3
Anthem Blue Cross	Keenan & Associates	60%	3
Anthem Blue Cross	City of Los Angeles (CA)	62%	3
Anthem Blue Cross	City of Los Angeles Department of Water and Power (CA)	62%	3
Anthem Blue Cross	State Compensation Insurance Fund (CA)	62%	3
Anthem Blue Cross	City of Los Angeles (CA)	63%	3
Anthem Blue Cross	Elite Claims Management	63%	3
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	63%	3
Anthem Blue Cross	Tristar Risk Management	63%	3
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	63%	3
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	64%	3
Anthem Blue Cross	Insurance Company of the West	66%	3
Anthem Blue Cross	Midwest Insurance	66%	3
Anthem Premier MPN	Farmers Insurance	66%	3
Anthem Blue Cross	Acclamation Insurance Management Services	67%	3
Anthem Blue Cross	Keenan & Associates	68%	3
Anthem Blue Cross	Pacific Compensation Insurance Company	69%	3
Anthem Blue Cross	State Compensation Insurance Fund (CA)	69%	3
Anthem PPO Contract	Berkshire Hathaway Homestate Companies	69%	3
Anthem Premier MPN	Guard Insurance Group	69%	3
Anthem Blue Cross	Acclamation Insurance Management Services	70%	3
Anthem Blue Cross	City of Los Angeles (CA)	70%	3
Anthem Blue Cross	Keenan & Associates	70%	3
Anthem Blue Cross	Insurance Company of the West	71%	3
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	71%	3
Anthem Blue Cross	Berkshire Hathaway Homestate Companies	72%	3
Anthem Blue Cross	State Compensation Insurance Fund (CA)	72%	3
Anthem Blue Cross	Insurance Company of the West	73%	3
Anthem PPO Contract	State Compensation Insurance Fund (CA)	75%	3
Anthem Blue Cross	Keenan & Associates	76%	3
Anthem PPO Contract	State Compensation Insurance Fund (CA)	76%	3
Anthem Blue Cross	Keenan & Associates	78%	3
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	83%	3
Anthem PPO Contract	State Compensation Insurance Fund (CA)	83%	3
Anthem Blue Cross	Broadspire	85%	3
Anthem Blue Cross	Elite Claims Management	85%	3
Anthem Blue Cross	Sempra Energy Employee Care Services	85%	3
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	4%	2
Anthem Blue Cross	Broadspire	39%	2
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	39%	2
Anthem Blue Cross	Keenan & Associates	43%	2
Anthem Blue Cross	AmTrust North America	47%	2
Anthem Blue Cross	Insurance Company of the West	48%	2
Anthem Blue Cross	AmTrust North America	49%	2
Anthem Blue Cross	Berkshire Hathaway Homestate Companies	51%	2
Anthem Blue Cross	Farmers Insurance	52%	2
Anthem Blue Cross Pend and Transmit	Sedgwick Claims Management Services	52%	2
MPN-Anthem Blue Cross	Sedgwick Claims Management Services	52%	2
Anthem Blue Cross	Farmers Insurance	53%	2
Anthem Blue Cross	State Compensation Insurance Fund (CA)	53%	2
Anthem Blue Cross	The Zenith	53%	2
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	54%	2
Anthem Blue Cross	Keenan & Associates	56%	2
Anthem PPO Contract	Berkshire Hathaway Homestate Companies	56%	2
Anthem PPO Contract	Liberty Mutual Insurance	56%	2
Anthem Blue Cross	Farmers Insurance	58%	2
Anthem Blue Cross	Midwest Insurance	58%	2
Anthem Blue Cross	Pacific Compensation Insurance Company	58%	2
Anthem Blue Cross	State Compensation Insurance Fund (CA)	58%	2
Anthem Blue Cross	Tokio Marine Management	58%	2
Anthem Blue Cross Pend and Transmit	Sedgwick Claims Management Services	58%	2
Anthem Blue Cross	California Insurance Guarantee Association	59%	2
Anthem Blue Cross	Farmers Insurance	59%	2
Anthem Blue Cross	Guard Insurance Group	59%	2
Anthem Blue Cross	Pacific Compensation Insurance Company	59%	2
Anthem Blue Cross	Sedgwick Claims Management Services	59%	2
Anthem Blue Cross Pend and Transmit	Sedgwick Claims Management Services	59%	2
Anthem Premier MPN	Berkshire Hathaway Homestate Companies	59%	2
Procura/Anthem Blue Cross	ESIS, Inc.	59%	2
Anthem Blue Cross	AmTrust North America	60%	2
Anthem Blue Cross	Insurance Company of the West	60%	2
Anthem Blue Cross	Broadspire	61%	2
Anthem Blue Cross	AmTrust North America	63%	2
Anthem Blue Cross	Acclamation Insurance Management Services	64%	2
Anthem Blue Cross	AmTrust North America	64%	2
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	64%	2
Anthem Blue Cross	Broadspire	65%	2
Anthem Blue Cross	City of Los Angeles (CA)	65%	2
Anthem Blue Cross	Keenan & Associates	65%	2
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	65%	2
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	65%	2
Anthem PPO Contract	State Compensation Insurance Fund (CA)	67%	2
Anthem Blue Cross	Berkshire Hathaway Homestate Companies	68%	2
Anthem Blue Cross	The Zenith	68%	2
Anthem Blue Cross	Guard Insurance Group	69%	2
Anthem Blue Cross	Hanover Insurance Company	69%	2
Anthem Blue Cross Pend and Transmit	Athens Administrators	69%	2
Anthem PPO Contract	AmTrust North America	69%	2
Anthem PPO Contract	Keenan & Associates	69%	2
Anthem Premier MPN	Sedgwick Claims Management Services	69%	2
Anthem Worker's Comp	Broadspire	69%	2
Procura/Anthem Blue Cross	ESIS, Inc.	69%	2
Anthem Blue Cross	Broadspire	70%	2
Anthem Blue Cross	Elite Claims Management	70%	2
Anthem Blue Cross	The Zenith	70%	2
Anthem Blue Cross	Liberty Mutual Insurance	72%	2
Anthem Blue Cross	Acclamation Insurance Management Services	73%	2
Anthem Blue Cross	Acclamation Insurance Management Services	75%	2
Anthem Blue Cross	City of Los Angeles Department of Water and Power (CA)	75%	2
Anthem Blue Cross	Sempra Energy Employee Care Services	75%	2
Anthem PPO Contract	AIG Claims, Inc.	75%	2
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	76%	2
Anthem Blue Cross	State Compensation Insurance Fund (CA)	77%	2
Anthem PPO Contract	State Compensation Insurance Fund (CA)	78%	2
Anthem Blue Cross	Acclamation Insurance Management Services	79%	2
Anthem Blue Cross	ARGO - Argonaut Insurance Company	85%	2
Anthem Blue Cross	City of Los Angeles Department of Water and Power (CA)	85%	2
Anthem Blue Cross	Liberty Mutual Insurance	85%	2
Anthem Blue Cross Pend and Transmit	Sedgwick Claims Management Services	85%	2
Anthem Premier MPN	Farmers Insurance	85%	2
Procura/Anthem Blue Cross	Employers Compensation Insurance Company	85%	2
Anthem Blue Cross	Keenan & Associates	0%	1
Anthem Blue Cross	Broadspire	6%	1
Anthem Blue Cross	AmTrust North America	15%	1
Anthem Blue Cross	Broadspire	19%	1
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	21%	1
Anthem Blue Cross	Sedgwick Claims Management Services	23%	1
Anthem Blue Cross	Sedgwick Claims Management Services	28%	1
Anthem PPO Contract	Berkshire Hathaway Homestate Companies	30%	1
Anthem Blue Cross	Tokio Marine Management	33%	1
Anthem Blue Cross	AmTrust North America	35%	1
Anthem Blue Cross	City of Los Angeles (CA)	38%	1
Anthem Blue Cross	Pacific Compensation Insurance Company	38%	1
Anthem Blue Cross	Insurance Company of the West	40%	1
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	40%	1
Anthem Blue Cross	AmTrust North America	41%	1
Anthem Blue Cross	California Insurance Guarantee Association	41%	1
Anthem PPO Contract	State Compensation Insurance Fund (CA)	41%	1
Anthem Blue Cross	Insurance Company of the West	44%	1
Anthem Blue Cross	Liberty Mutual Insurance	44%	1
Anthem Blue Cross	ARGO - Argonaut Insurance Company	45%	1
Anthem Blue Cross	California Insurance Guarantee Association	45%	1
Anthem Blue Cross	Sedgwick Claims Management Services	45%	1
Anthem Blue Cross	Liberty Mutual Insurance	46%	1
MPN-Anthem Blue Cross	Sedgwick Claims Management Services	47%	1
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	48%	1
Anthem Blue Cross	State Compensation Insurance Fund (CA)	48%	1
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	48%	1
Anthem PPO Contract	Keenan & Associates	48%	1
Anthem PPO Contract	Liberty Mutual Insurance	48%	1
Anthem Premier MPN	Farmers Insurance	48%	1
Anthem Blue Cross	Berkshire Hathaway Homestate Companies	49%	1
Anthem Blue Cross	Broadspire	49%	1
Anthem PPO Contract	State Compensation Insurance Fund (CA)	49%	1
Anthem Premier MPN	Sedgwick Claims Management Services	49%	1
Anthem Blue Cross	Church Mutual Insurance Company	50%	1
Anthem Blue Cross	Keenan & Associates	50%	1
Anthem PPO Contract	State Compensation Insurance Fund (CA)	50%	1
Anthem Blue Cross	Acclamation Insurance Management Services	51%	1
Anthem Blue Cross	California Insurance Guarantee Association	51%	1
Anthem Blue Cross	Elite Claims Management	51%	1
Anthem Blue Cross	Pacific Compensation Insurance Company	51%	1
Anthem Blue Cross	Tokio Marine Management	51%	1
Anthem Premier MPN	Farmers Insurance	51%	1
Anthem Blue Cross	Acclamation Insurance Management Services	52%	1
Anthem Blue Cross	Church Mutual Insurance Company	52%	1
Anthem Blue Cross	City of Los Angeles (CA)	52%	1
Anthem PPO Contract	Berkshire Hathaway Homestate Companies	52%	1
Anthem PPO Contract	Pacific Compensation Insurance Company	52%	1
Anthem Blue Cross	AmTrust North America	53%	1
Anthem Blue Cross	Elite Claims Management	53%	1
Anthem Blue Cross	Tristar Risk Management	53%	1
Anthem PPO Contract	Liberty Mutual Insurance	53%	1
Anthem Premier MPN	Farmers Insurance	53%	1
Anthem Worker's Comp	State Compensation Insurance Fund (CA)	53%	1
Anthem Blue Cross	Acclamation Insurance Management Services	54%	1
Anthem Blue Cross	Broadspire	54%	1
Anthem Blue Cross	City of Los Angeles Department of Water and Power (CA)	54%	1
Anthem Blue Cross	Acclamation Insurance Management Services	55%	1
Anthem Blue Cross	AmTrust North America	55%	1
Anthem Blue Cross	City of Los Angeles Department of Water and Power (CA)	55%	1
Anthem Blue Cross	Elite Claims Management	55%	1
Anthem Blue Cross	City of Los Angeles (CA)	56%	1
Anthem Blue Cross	Insurance Company of the West	56%	1
Anthem Blue Cross	Broadspire	57%	1
Anthem PPO Contract	State Compensation Insurance Fund (CA)	57%	1
Anthem Blue Cross	California Insurance Guarantee Association	58%	1
Anthem Blue Cross	Church Mutual Insurance Company	58%	1
Anthem Blue Cross	Elite Claims Management	58%	1
Anthem Worker's Comp	City of Torrance (CA)	58%	1
Anthem Blue Cross	Berkshire Hathaway Homestate Companies	59%	1
Anthem Blue Cross	ESIS, Inc.	59%	1
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	59%	1
Anthem Blue Cross	Risico Claims Management, Inc.	59%	1
Anthem Blue Cross	The Zenith	59%	1
Anthem Blue Cross Pend and Transmit	Athens Administrators	59%	1
Anthem PPO Contract	Keenan & Associates	59%	1
Anthem Worker's Comp	American Equity Underwriters	59%	1
Anthem Worker's Comp	Broadspire	59%	1
Anthem Blue Cross	Sempra Energy Employee Care Services	60%	1
Anthem Blue Cross	Tristar Risk Management	60%	1
Anthem PPO Contract	Liberty Mutual Insurance	60%	1
Anthem PPO Contract	State Compensation Insurance Fund (CA)	60%	1
Anthem Blue Cross	Acclamation Insurance Management Services	61%	1
Anthem Blue Cross	Berkshire Hathaway Homestate Companies	61%	1
Anthem Blue Cross	Farmers Insurance	61%	1
Anthem Blue Cross	Insurance Company of the West	61%	1
Anthem Blue Cross	Keenan & Associates	61%	1
Anthem Blue Cross	Tristar Risk Management	61%	1
Anthem PPO Contract	State Compensation Insurance Fund (CA)	61%	1
Anthem Blue Cross	Acclamation Insurance Management Services	62%	1
Anthem Blue Cross	Athens Administrators	62%	1
Anthem Blue Cross	Berkshire Hathaway Homestate Companies	62%	1
Anthem Blue Cross	California Insurance Guarantee Association	62%	1
Anthem Blue Cross	Church Mutual Insurance Company	62%	1
Anthem Blue Cross	Tokio Marine Management	62%	1
Anthem PPO Contract	Liberty Mutual Insurance	62%	1
Anthem Blue Cross	Farmers Insurance	63%	1
MPN-Anthem Blue Cross	Sedgwick Claims Management Services	63%	1
Anthem Blue Cross	Church Mutual Insurance Company	64%	1
Anthem Blue Cross	Keenan & Associates	64%	1
Anthem Blue Cross	Elite Claims Management	65%	1
Anthem Blue Cross	Insurance Company of the West	65%	1
Anthem Blue Cross Pend and Transmit	Sedgwick Claims Management Services	65%	1
Anthem PPO Contract	State Compensation Insurance Fund (CA)	65%	1
Anthem Worker's Comp	State Compensation Insurance Fund (CA)	65%	1
Anthem Blue Cross	Broadspire	66%	1
Anthem Blue Cross	Keenan & Associates	66%	1
Anthem Blue Cross	Liberty Mutual Insurance	66%	1
Anthem Blue Cross	Tristar Risk Management	66%	1
Anthem PPO Contract	State Compensation Insurance Fund (CA)	66%	1
Anthem Blue Cross	City of Los Angeles (CA)	67%	1
Anthem Blue Cross	Guard Insurance Group	67%	1
Anthem Blue Cross	Helmsman Management Services	67%	1
Anthem Blue Cross	Acclamation Insurance Management Services	68%	1
Anthem Blue Cross	AmTrust North America	68%	1
Anthem Blue Cross	Broadspire	68%	1
Anthem Blue Cross	Sempra Energy Employee Care Services	69%	1
Anthem Blue Cross (MBW)	Guard Insurance Group	69%	1
Anthem PPO Contract	Farmers Insurance	69%	1
Anthem PPO Contract	Insurance Company of the West	69%	1
Anthem Worker's Comp	American Equity Underwriters	69%	1
Anthem Worker's Comp	Athens Administrators	69%	1
Anthem Worker's Comp	Los Angeles County Metropolitan Transit Authority (CA)	69%	1
Procura/Anthem Blue Cross	Employers Compensation Insurance Company	69%	1
Anthem Blue Cross	Innovative Risk Management	70%	1
Anthem Blue Cross	Liberty Mutual Insurance	70%	1
Anthem Blue Cross	Risico Claims Management, Inc.	70%	1
Anthem Blue Cross	Tristar Risk Management	70%	1
Anthem Blue Cross Pend and Transmit	Sedgwick Claims Management Services	70%	1
Anthem PPO Contract	State Compensation Insurance Fund (CA)	70%	1
MPN-Anthem Blue Cross	Sedgwick Claims Management Services	70%	1
Procura/Anthem Blue Cross	ESIS, Inc.	70%	1
Anthem Blue Cross	Church Mutual Insurance Company	71%	1
Anthem Blue Cross	Farmers Insurance	71%	1
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	71%	1
Anthem Blue Cross	State Compensation Insurance Fund (CA)	71%	1
Anthem Worker's Comp	City of Torrance (CA)	71%	1
Procura/Anthem Blue Cross	ESIS, Inc.	71%	1
Anthem Blue Cross	Church Mutual Insurance Company	72%	1
Anthem Blue Cross	Hanover Insurance Company	72%	1
Anthem Blue Cross	Midwest Insurance	72%	1
Anthem Blue Cross	Sedgwick Claims Management Services	72%	1
Anthem Blue Cross	The Zenith	72%	1
Anthem Blue Cross	Tokio Marine Management	72%	1
Anthem PPO Contract	Berkshire Hathaway Homestate Companies	72%	1
Anthem PPO Contract	Liberty Mutual Insurance	72%	1
Procura/Anthem Blue Cross	ESIS, Inc.	72%	1
Anthem Blue Cross	Berkshire Hathaway Homestate Companies	73%	1
Anthem Blue Cross	Broadspire	73%	1
Anthem Blue Cross	Keenan & Associates	73%	1
Anthem Blue Cross	The Zenith	73%	1
Anthem PPO Contract	State Compensation Insurance Fund (CA)	73%	1
Anthem Blue Cross	City of Los Angeles Department of Water and Power (CA)	74%	1
Anthem Blue Cross	Farmers Insurance	74%	1
Anthem Blue Cross	Keenan & Associates	74%	1
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	74%	1
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	74%	1
Anthem PPO Contract	State Compensation Insurance Fund (CA)	74%	1
Anthem Blue Cross	AmTrust North America	75%	1
Anthem Blue Cross	California Insurance Guarantee Association	75%	1
Anthem Blue Cross	City of Los Angeles (CA)	75%	1
Anthem Blue Cross	Liberty Mutual Insurance	75%	1
Anthem PPO Contract	Liberty Mutual Insurance	75%	1
Anthem Premier MPN	Farmers Insurance	75%	1
Anthem Blue Cross	Acclamation Insurance Management Services	76%	1
Anthem Blue Cross	Sedgwick Claims Management Services	76%	1
Anthem Blue Cross	Tristar Risk Management	76%	1
Anthem Blue Cross (MBW)	Broadspire	76%	1
Anthem Blue Cross	Acclamation Insurance Management Services	77%	1
Anthem Blue Cross	Church Mutual Insurance Company	77%	1
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	77%	1
Anthem Blue Cross Pend and Transmit	Sedgwick Claims Management Services	77%	1
Anthem Blue Cross	Broadspire	78%	1
Anthem Blue Cross	Elite Claims Management	78%	1
Anthem Blue Cross	Tristar Risk Management	78%	1
Anthem Blue Cross	Berkshire Hathaway Homestate Companies	79%	1
Anthem Blue Cross	Broadspire	79%	1
Anthem Blue Cross	Insurance Company of the West	79%	1
Anthem Blue Cross	Keenan & Associates	79%	1
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	79%	1
Anthem Blue Cross	OneCall Care Management Network	79%	1
Anthem Blue Cross	Insurance Company of the West	80%	1
Anthem Blue Cross	Los Angeles County Metropolitan Transit Authority (CA)	80%	1
Anthem PPO Contract	State Compensation Insurance Fund (CA)	80%	1
Anthem Premier MPN	Farmers Insurance	80%	1
Anthem Blue Cross	Insurance Company of the West	82%	1
Anthem Blue Cross	City of Los Angeles (CA)	83%	1
Anthem Blue Cross	Insurance Company of the West	83%	1
Anthem Premier MPN	Farmers Insurance	83%	1
Anthem Blue Cross	City of Los Angeles (CA)	84%	1
Anthem Blue Cross	Berkshire Hathaway Homestate Companies	85%	1
Anthem Blue Cross	City of Torrance (CA)	85%	1
Anthem Blue Cross	Hanover Insurance Company	85%	1
Anthem Blue Cross	Intact Insurance Specialty Solutions	85%	1
Anthem Blue Cross	Pacific Compensation Insurance Company	85%	1
Anthem Blue Cross	The Zenith	85%	1
Anthem PPO Contract	Keenan & Associates	85%	1
Anthem Blue Cross	Tristar Risk Management	87%	1
Anthem Blue Cross (MBW)	Berkshire Hathaway Homestate Companies	90%	1
Anthem PPO Contract	Zurich Insurance North America	90%	1
Anthem Blue Cross	Insurance Company of the West	91%	1
Anthem Blue Cross	City of Los Angeles Department of Water and Power (CA)	95%	1

On average, claims administrators applying Anthem discounts reimburse this provider at 67% of OMFS rates. The losses represent a massive chunk of the provider’s revenue, siphoned away as Anthem rings the dinner bell for payers far and wide.

To really grasp the impact on this practice, let’s play with some hypothetical numbers.

The record above includes 3,559 bills. Say for simplicity’s sake that each one of those bills originally totalled $100 at OMFS rates. In other words, per the state fee schedule, the provider is (hypothetically) owed $100 per bill for every bill:

Total Number of Bills	3,559
(Hypothetical) OMFS Reimbursement Rate per Bill	$100
Total Reimbursement Under (Hypothetical) OMFS	$355,900
Total Reimbursement After Anthem Discounts	$233,403
Total Loss to Provider	$122,497

At $100 per bill, working with Anthem would cost this provider over ⅓ of the revenue generated by the services represented in the table. It begs the question: is it worth it? Did signing this discount contract bring the provider enough new patients for it to make financial sense?

What, exactly, is the true return on investment here?

Our suspicion is that in many cases, providers without access to data like this have no idea what they’re losing — and if they did, they would refer Anthem for a procedure in which their network contract is surgically placed where the proverbial sun don’t shine.

Leveling the Playing Field in Workers’ Comp

As advocates for a fair system, we warn providers to be careful when considering network discount contracts. We offer software and services that give providers a clear picture of how dangerous some contracts can be. We encourage providers to stay informed and proactively guard their revenue from those who would pilfer it.

That said, we have to ask: where is the state on this?

The Division of Workers’ Compensation (DWC) determines appropriate reimbursement for medical services, carefully calculating OMFS rates based on Medicare, Relative Values, geographic differences, and more. They create rules governing the allowable terms of network agreements, including transparency regarding the leasing of network discounts to (apparently) legions of payers.

To offer a transparent agreement to a fully informed provider who understands the tradeoffs, in a well-regulated environment, is no crime. What we’re seeing, however, does not fit that description. In practice, these contracts can do real damage to providers’ revenue— and the DWC’s efforts to inform and protect providers are inadequate.

To the insurers, bill reviews, network contracting entities, and other a-sordid sidekick vendors profiting from discount networks, the OMFS seems to serve only as a baseline from which to carve out revenue for themselves — and, we have to ask, in exchange for what? To these entities, regulations seem like obstacles to be skirted, not rules to be respected.

Providers are paying the price, literally, in lost income. Patients pay it figuratively, as fewer and fewer providers agree to submit themselves to workers’ comp as currently managed.

New parameters for discount contracts should be established in workers’ comp. Providers are in the wind, pit against companies with serious data, resources, and personnel dedicated to creating profit by making the treatment of injured workers less profitable.

The playing field needs leveling, now.

Make RFAs, billing, and appeals easier than ever — and get paid faster. DaisyBill empowers providers to collect what’s owed in record time. Contact us to learn how we can help your practice.

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