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Anthem:  PPO Discounts Result in Payments BELOW Medicare

Anthem: PPO Discounts Result in 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:

  1. $97.27 to the provider (52% of the OMFS reimbursement) and
  2. $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:

  1. Why does the California workers’ comp system enrich Anthem Blue Cross in this manner?
  2. 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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