Does the Marriott hotel chain know where the money really goes when it pays for its employees’ medical treatment?

Self-insured and with its own in-house claims administration, Marriott is a perfect example of an employer that ostensibly issues payment for the providers treating its injured workers — but may or may not be aware of the detours that payment takes, or the many, many network entities presumably taking a cut of the providers’ reimbursements.

Below, we share several examples of how networks including Encompass Specialty Network, Advanet/Paradigm, and Priority Care Solutions/Triton place themselves in a perfect position to intercept the employer dollars designated for restoring Marriott workers to health.

We can’t say how exactly the spoils are divided, but as always, there’s the big question: what are Marriott or its injured employees getting out of this arrangement, besides the opportunity to help middleperson entities profit?

Marriott, Genex, and the Network Problem

As a self-insured employer, Marriott is responsible for covering the costs of its injured workers’ treatment. Marriott also self-administers its workers’ comp claims. So one could be forgiven for assuming that the transaction is usually simple: doctor treats and bills, Marriott pays.

If only it were so straightforward.

Instead, Marriott employs Genex for bill review services. Genex does not simply adjudicate providers’ bills per the fee schedule and pay these providers. Instead, Genex sends Marriott’s reimbursement payments to various networks. These networks then take a slice of the reimbursement before passing the remainder on to the provider.

How does daisyBill know about this? By mistake, actually.

We are privy to the examples below (and 10,000+ others like it) because bill review companies erroneously send daisyBill (invalid) electronic Explanations of Review (e-EORs) revealing which networks the bill reviews pay, and the amount, before the networks pay the providers.

Marriott Pays Advanet/Paradigm

In our first example, we have an EOR from Marriott/Genex in which Genex determined Marriott would pay $216.55, which equals 94% of the amount owed per the Official Medical Fee Schedule (OMFS).

But knowingly or not, Marriott did not pay the doctor — Marriott paid Advanet.

You may be wondering, exactly how does the provider get paid?

In this case, Paradigm Specialty Networks paid the provider, but not before apparently taking a little somethin’ somethin’ for their trouble. Paradigm left the provider $200.35, equal to 87% of the OMFS rate (and equal to 117% of the Medicare rate, even though OMFS rates are set at roughly 134% of Medicare rates in 2022).

Paradigm justified the payment discount by citing “Adva-net” on the EOR. Don’t feel bad if you find the webs of relationships between different network entities like Paradigm and Advanet confusing; this network system is a feeding frenzy, and it can be hard to tell where one shark ends and the next begins.

Adding insult to injury, it took Marriott 20 calendar days to pay Advanet/Paradigm, which in turn took 10 more calendar days to pay the provider — despite California regulations requiring payment for medical e-bills within 15 working days.

Marriott Pays Priority Care Services/Triton/USAMCO

In the next example, rather than paying the doctor, Marriott (via Genex) paid Priority Care Solutions/Triton Healthcare Partners $751.58, or 95% of the OMFS rate of $787.39.

But Priority Care/Triton couldn’t let too much of that reimbursement trickle down to the provider who actually treated Marriott’s employee. In this case, Priority cut $121.66, leaving the provider $629.92, (equal to 80% of the OMFS rate and 107% of the Medicare rate).

Cited on the EOR: the USAMCO network, yet another layer in the rancid onion of workers’ comp networks, meta-networks of networks, and meta-meta-networks of meta-networks.

Marriott Pays Encompass/Paradigm…or “Prime Heal,” or Something

In our final example (for today), Marriott/Genex paid Encompass Specialty Network (and friends).

The amount due per the OMFS was $206.81; Marriott/Genex was willing to pay $200.61, equal to 97% OMFS.

In an NFL-worthy interception, Encompass nabbed the Marriott payment on its way to the doctor, reducing it by $6.20 and citing “Paradigm Specialty Networks or Prime Heal” on the EOR.

Yes, Encompass cited two different, apparently unrelated networks and put the word “or” in between them on an official document explaining bill adjudication.  

This supremely lazy act of EOR multiple choice says all we need to know: One way or another, Encompass was reducing this doctor’s revenue, and could barely be bothered to justify it with any specificity. The EOR may as well cite “...y’know, ‘cause networks or whatever (just get over it).”

Moreover, Genex took 19 days to remit Marriott’s money to Encompass, which then delayed payment to the provider a further 14 days — meaning this provider didn’t see a dime until 33 calendar days after submitting an e-bill that was due in 15 working days.

This is the shell game wrought by Medical Provider Networks (MPNs), Preferred Provider Organizations (PPOs) and other opaque, nebulous network entities in California — and by state legislators and regulators who seem perfectly content to allow this payment chaos.

This is one reason (among many) that providers avoid treating injured workers.

The OMFS may establish reasonable reimbursement amounts, but those amounts are nothing more than a pie to be sliced up and distributed to the middleperson companies feeding at the trough of California workers’ comp.

Doctors cannot predict revenue in this environment; they can only choose to treat injured workers at a potential loss (as many have), or give up on workers’ comp altogether (as many have).

Employers like Marriott must ask themselves what role they’re playing — unwittingly or otherwise — in making it ever more difficult for their injured workers to access care.  

Make workers’ comp easy. Harness the power of daisyBill software, data, and expertise for faster, better workers’ comp billing. Request a demo below.

REQUEST DEMO