In a revelation with severe implications for California workers’ comp, CEO Todd Breeden of America’s Choice Provider Network (ACPN) reported that Triton Healthcare Partners improperly applied a 30% ACPN contractual discount to a provider’s bill for Intact Insurance. 

The good news: Mr. Breeden took the admirable step of reporting Triton’s “error” directly to daisyBill. Mr. Breeden also contacted Triton and insisted they return the improperly hijacked funds to the provider.

The bad news: Our data reveals that other claims administrators and Triton have repeatedly siphoned the doctor’s revenue by citing the inapplicable ACPN discount agreement.

The worse news: While Intact Insurance and Triton were caught (along with other claims administrators), there are no consequences when claims administrators illicitly funnel employers’ workers’ comp dollars away from providers and into the bank accounts of these Pilfering Provider Organizations (PPOs).

While doctors’ revenue is reduced by PPO schemes, the real victims of these schemes are employers and their injured workers. Instead of paying for the care required to heal injured workers, California legislators and regulators allow payers to siphon employers’ workers’ comp premiums to enrich PPOs like Triton and its confederates. 

Read on to see precisely how Intact, Triton & co misused the ACPN discount contract, and how your practice is likely a victim of similar “errors.”

Intact Insurance & Triton: Chain of Discount Abuse

Last week, daisyBill reported that Triton, Apricus (formerly PCS), and their “affiliated network partners” reduced a provider’s reimbursement for treating an injured worker to just 69% of the amount due under California’s Official Medical Fee Schedule (OMFS). Triton incorrectly cited an inapplicable ACPN discount contract to justify the reduction.

The article elicited strong responses, not the least of which came from Mr. Breeden — who was surprised to learn that an ACPN discount was applied.

Mr. Breeden, as CEO of ACPN, was quick to reach out to daisyBill and clarify that the ACPN contract in question does not apply to states with workers’ comp fee schedules, including California. He also expressed his intent to see to it that Triton reimburses the provider for the improperly used ACPN reductions.

Mr. Breeden stated that he reached out to Triton to demand Triton immediately refund the $121.81 that Triton/Apricus took from this doctor. According to Breeden, “First, I corrected the problem. Now, the problem needs to be fixed.”

(Bad news: The misuse of the ACPN contract extends far beyond a single bill. This doctor is left with a string of bills reduced to only 70% of the amount allowed by the OMFS, and with few options to recover the funds).

Below we expose the ‘workflow’ by which Intact Insurance and Triton made off with 31% of the reimbursement due to this doctor for treating an injured worker.  

Step 1. The provider appropriately billed the actual claims administrator, Intact Insurance, as the daisyBill Bill History below shows.

Step 2. Instead of reimbursing the provider, Intact Insurance remitted payment to the Triton/Apricus cabal. Below is the Explanation of Review (EOR) Intact Insurance sent to the doctor, except the Payee is Priority Care Solutions Inc. (aka Triton, Apricus, & pals).

This EOR exposes that Intact Insurance paid Priority Care Solutions instead of paying the doctor.  

EMPLOYER ALERT: daisyBill data includes hundreds of thousands of similar EORs, proving that claims administrators routinely divert employer dollars through PPOs instead of paying doctors directly.

Step 3. Then Triton — rather than Intact Insurance — sent the provider a second EOR. This Triton EOR shows that Triton & pals took significant PPO reductions, and justified the cuts by citing an “Amer Choice Prov Netwrk WC” (ACPN) discount contract.

The EOR included an introduction to the Triton cabal and a brief, opaque “explanation” of the group’s supposed right to apply network discounts:

“...Your company has been identified as being contracted with one of our affiliated network partners…”

“Affiliated Network Partners:” A System-Wide Crisis

This same “affiliated network” process of diverting revenue away from doctors routinely occurs in workers’ comp.

The webs of relationships between claims administrators and PPOs are hopelessly tangled. The opacity is the point; when no one knows which discounts apply to a given bill, claims administrators can slap any contract name on the EOR, and chances are that no one inspects too closely.  

System-Wide Data: daisyBill maintains an OMFS reimbursement data page that calculates the dollar amount claims administrator discount schemes have collectively siphoned away from our provider clients. Since January 1, 2021, claims administrators have failed to reimburse over $33 million due to these providers per the OMFS.  

Employers, that is $33 million that did NOT pay for treatment provided to your injured workers. (Note: this data represents each instance where the claims administrator paid the provider an amount below the amount allowed by the OMFS).

While daisyBill’s 4,000+ providers constitute a large percentage of providers in California’s workers’ comp system, this $33 million figure does not represent monies diverted from all California providers. In fact, it’s possible that non-daisyBill providers are reimbursed at even lower rates, simply because they lack access to the data that sheds light on these discount schemes.

Stay tuned to this space. Soon, we will report and unpack more data around the widespread, systemic issue of these shadow discounts, foisted on providers by California’s PPO-friendly “pay-to-play” workers’ comp system.

Make it harder for claims admins to improperly deny payment. Make it easier for your office to get paid, in full and on time. daisyBill has the tools — reach out to learn more.

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