Many payers delegate bill review to an outside entity, trusting the bill review vendor to properly reimburse providers. But when a provider disputes a denial or adjustment, it may not always be prudent for payers to assume the bill review is correct or has the payer’s best interest in mind — particularly with regard to PPO and other dubious discount contracts.
A dispute involving the City/County of San Francisco (CCSF) is a perfect example.
CCSF’s bill review, EK Health, applied a still-unsubstantiated Coventry PPO discount to a provider bill, launching a dispute. When our blog alerted CCSF to the problem, CCSF took strong measures, insisting that unless Coventry could produce a contract validating the discounts, EK Health must reprocess the bills and reimburse the provider 100% of the amount due per the California Official Medical Fee Schedule (OMFS).
It is truly heartening to see CCSF move decisively in defense of providers, who are under siege from entities like Coventry and EK Health. If all claims administrators were as proactive as CCSF, more providers would be willing to treat injured workers.
CCSF Takes Action To Protect Provider
After reading our previous blog post on this dispute, CCSF began its own investigation into the disputed PPO reductions. While the Division of Workers’ Compensation (DWC) fell for EK Health and Coventry’s nonsense, CCSF did not.
Instead, CCSF insisted that Coventry offer the provider proof of a contractual discount. In response to CCSF’s demand, Coventry sent the provider’s 2004 application to join the Coventry network. Coventry failed to produce a PPO agreement, signed contract, or any other document that allowed Coventry to skim the provider’s revenue.
When Coventry failed to substantiate the discount, CCSF took what we view as exemplary steps. On behalf of their injured employees and the providers who care for them, CCSF instructed EK Health representatives:
“If you cannot produce the documentation, and since our MPN MOU/Acknowledgements specifically state that we will only take the PPO discount where there is voluntary participation in a PPO network, please reprocess the bills to exclude the discount on appeal.”
CCSF’s proactive steps stopped the EK/Coventry duo from tainting the good name of CCSF, an entity uniformly held in high regard by providers.
CCSF: A Solid Reputation With Providers
DaisyBill clients speak favorably about working with CCSF, an organization that by their own account takes pains to keep providers happy.
As Lesley Anderson, MD, remarked in response to our first blog post about this dispute, CCSF isn’t afraid to confront bill review or PPO organizations when providers object to mistreatment:
I have cared for CCSF patients for 30+ years. They are one of my most responsive WC payors to concerns. Yes, they have taken PPO discounts, and when notified, they ceased to do so, with the same PPO that is actually the predator here.
CCSF has been terrific to work with….they are very responsive to their doc’s concerns.
If more claims administrators approached disputes with CCSF’s respect for the rules, there would be far less dispute-related friction in workers’ comp.
The PPO Discount Trap
As CCSF’s investigation confirms, for providers, PPO discount contracts can spread in untraceable, out-of-control, ways.
PPOs like Coventry/First Health lease reimbursement discounts out to payer after payer, spreading reductions across all of a provider’s reimbursements. PPO entities specialize in finding creative ways to apply PPO discounts, like tying inclusion in Medical Provider Networks (MPNs) to PPO affiliation.
The result is that providers are often stunned to discover significant reductions in their reimbursements, based on PPO discount agreements they never understood. Unfortunately, the webs of MPNs and PPOs are so complex, keeping track of it all proves bewildering for providers — and bill reviews like EK Health know it.
But as this provider’s dispute revealed, organizations like EK Health and Coventry can lose the plot themselves. That’s why it’s important for claims administrators to take provider appeals seriously, as CCSF did when they displayed the leadership to question their own bill review.
How much revenue is your practice losing to network discounts? DaisyBill gives you a clear picture of your reimbursements, and whether they’re aligned with OMFS rates. Reach out to learn more.