A series of emails between a California doctor and Coventry expose the unvarnished truth about Preferred Provider Organizations (PPOs) and Medical Provider Networks (MPNs).

Every doctor should read the exchange below, in which Coventry pressured a doctor to sacrifice reimbursement in exchange for inclusion in (what turned out to be) non-approved MPNs. After reading, doctors contracted with Coventry may consider taking the necessary steps to cancel their agreement.

Shared with daisyBill by the doctor, the emails show Coventry, a workers’ comp “specialty network,” making an embarrassingly inept attempt to answer two very basic but critical questions every provider should ask before signing a PPO contract:

1. In exchange for accepting discounted reimbursement rates, which specific insurer or employer MPNs will I be added to?
2. Will Coventry lease/sell/transfer the discounted reimbursement rates with other entities, which will also discount my reimbursements?

These are straightforward, simple, eminently reasonable questions every doctor must ask before agreeing to give up practice revenue to any PPO or network. The emails below reveal:

• Coventry could not identify a single insurer or self-insured employer that maintains an approved Coventry MPN.
• The only MPNs Coventry representatives named are currently revoked, terminated, or withdrawn.

This exchange was the result of a provider simply questioning the actual benefits of signing a PPO or network discount contract. Despite Coventry’s non-answers, the specialty network provided the only answer doctors really need: the advantages of network participation are often a mirage.

Doctor Questions PPO/MPN Benefits

Coventry (part of the Mitchell/Genex/Coventry network knot under the umbrella of Enlyte) approached the doctor to sign an updated discount agreement that included even further reduced reimbursement rates, as the emails below show.

Understandably, the doctor was not inclined to give away even more revenue to Coventry, at least not without a clear idea of the return on investment.

Predictably, Coventry dangled the promise of MPN membership as an enticement.

Following our recent webinar on MPNs and PPO discount contracts, the doctor reached out to daisyBill for information on navigating the negotiations with Coventry.

daisyBill urged the doctor to press Coventry for details on MPN membership, and on potential discount-sharing under the proposed new agreement. Our message to the doctor is below (and every California provider should consider it).

Wisely, the doctor insisted on a clearer picture of the supposed benefits of the Coventry contract — the doctor even pointed out to Coventry that the Division of Workers’ Compensation (DWC) listed zero approved Coventry MPNs.

Coventry’s MPN Mirage

Coventry responded to the doctor’s questions, claiming there were “active insurers listed on the DWC website under Coventry MPN.”  

Spoiler alert #1: There are not.

Coventry also named two specific MPNs the doctor would have access to:

1. First Health CompAmerica Select HCO and
2. First Health CompAmerica Primary HCO
   

Spoiler alert #2: Neither MPN is listed as approved on the DWC MPN list.

The email acknowledges that signing the Coventry agreement and sacrificing reimbursement does not guarantee the doctor will be included in any employer or insurer MPN:  “If you are part of the First Health Select, Primary or Coventry MPNs, you still may not be part of a specific carrier’s MPN.”  

Spoiler alert #3: California Labor Code Section 4616(d) instructs that only insurers and self-insured employers may determine which providers may treat the workers they cover.

Research Reveals Coventry MPN Statuses

A simple search of the DWC MPN list for “Coventry” reveals three pages of results. For every single result where the MPN applicant is an insurer or self-insured employer, the ‘MPN Approval Status’ is either T (Terminated) or W (Withdrawn).

daisyBill also searched for the specific MPNs Coventry cited in their email to the provider, First Health CompAmerica Select HCO and First Health CompAmerica Primary HCO.

The results were unsurprising: pages upon pages of revoked, terminated, or withdrawn MPNs.

We can’t make this stuff up, and we wouldn’t if we could.

Providers are convinced that in order to treat injured workers, they must capitulate to PPO/network discount demands, or risk exclusion from the all-important MPNs. Yet time after time after time, we find that the value of membership in a given MPN is dubious at best.

In the case of Coventry, this exchange suggests that all doctors should gather the facts, and consider canceling their Coventry PPO contracts.

MPNs have been used to squeeze discounts from providers for too long. As this farcical exchange shows, a few simple questions and a little research is all it takes to reveal that often, the MPeror has no clothes.

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