Prime Health: Unsigned Contract Tale Continues

Prime Health: Unsigned Contract Tale Continues

Almost immediately after DaisyBill called out Prime Health Services (PHS) for questionable PPO practices, it was clear we struck a nerve. PHS attorneys sent DaisyBill a ‘please stop’ letter requesting among other actions that we retract our description of the curious timeline surrounding an unsigned PHS PPO contract.

In November 2020, DaisyBill contacted PHS on behalf of a provider to discuss the terms of a PHS Preferred Provider Agreement contract. The PHS representative admitted that their EVP had failed to sign the contract in question. Despite this admission, PHS subsequently produced a signed copy of the contract, dated September 2020.

PHS’s Unsigned, Signed, Then Unsigned Contract

In October 2020, a DaisyCollect provider started receiving reimbursements that were reduced to 30% below the amount allowed by the California Official Medical Fee Schedule (OMFS). The explanations of review (EORs) all listed Prime Health Services as the reason for the 30% reimbursement discount.

On November 19, 2020 DaisyBill contacted PHS to determine whether the PHS contract complied with California law (LAB §4609). In response to the inquiry, Leslie Losey, a PHS-designated National Network Development Executive, emailed:

“In terms of the signed, fully-executed contract- It looks like my EVP has not signed it yet. I have a printed copy lying on my desk now, and I will have him sign it as soon as he gets in today!”

Losey, a PHS executive, clearly stated that the contract was unsigned on November 19, 2020 (and on her desk). PHS attorneys now insist that Losey was mistaken. Citing administrative difficulties brought on by COVID, the PHS attorney letter claims “an unsigned version [of the contract] was uploaded by mistake.”

The letter from the PHS attorney also claims that despite the “new challenges with operating remotely,” the oversight was “immediately corrected” in November:

The agreement at issue was one of thirty agreements that were all uploaded on the same day in September 2020. For one of those thirty agreements, a blank agreement was accidentally uploaded for the particular provider referenced in the Defamatory Blog Posts. Once the oversight was recognized in November [emphasis added], it was immediately corrected.

Just because an unsigned version was uploaded by mistake, it does not follow that PHS did not have the signed agreement in its possession.

The agreement at issue had been signed by the provider and was effective, and no backdating occurred.

Despite the unsigned contract on Losey’s desk, attorneys insist that the PHS-signed copy had always been...somewhere, just not uploaded. And as it happens, “immediately corrected” may be yet another questionable claim from PHS.

In January 2021, PHS responded to another request for the signed contract by sending the unsigned contract, again. Despite the attorneys’ claims of PHS realizing the “mistake” in November, a PHS representative forwarded the unsigned contract as late as January.

Timeline of Events

When we made this dispute public on our blog, PHS attorneys sent the ‘please stop’ letter requesting the posts be removed, or else.

Instead, for the sake of clarity, we are using this space to delineate the facts of this dispute. Below is a timeline of events and actions regarding this PHS PPO contract, which reduces the provider’s reimbursement for treating injured workers by 30% for dozens of payers.

California legislators should ask this question: Why does California workers’ comp allow PHS and its bill review clients to profit by siphoning revenue intended for providers who help injured workers return to work?

Date

Action

9/4/2020

PHS begins reducing provider’s reimbursements to 70% OMFS.

11/18/2020

Daisybill requests documents referenced in the Provider Participation Agreement.

11/19/2020

A PHS representative confirms in an email to DaisyBill that the PPO contract remains unexecuted. The PHS representative promises to have a PHS executive sign the contract “as soon as he gets in today.”

1/15/2021

DaisyBill sends Second Review appeal disputing reimbursement reductions and demanding proof that the PPO contract is compliant with state regulations.

1/27/2021

A PHS representative emails DaisyBill a copy of the PHS contract that is NOT countersigned by PHS.

2/11/2021

The provider rescinds their agreement to the unexecuted contract.

2/11/2021

DaisyBill informs PHS that:

  • PHS failed to execute the contract, therefore, the contract never went into effect (as the contract language confirms).
  • The contract does not comply with state law (LAB § 4609).
  • The provider rescinded their agreement to the contract.

3/11/2021

A PHS representative contacts DaisyBill, insisting the PPO agreement is effective, referencing the unsigned contract.

3/30/2021

A PHS representative emails the provider in reference to the Second Review appeal, and attaches a copy of the contract signed by a PHS executive, dated 9/4/2020. 

4/6/2021

A PHS representative contacts DaisyBill in reference to additional Second Review appeals, insisting the reductions are correct per the PPO contract.

4/19/2021

Provider Warning: Prime Health Services (Part I) blog post published.

4/20/2021

Provider Warning: Prime Health Services (Part II) blog post published.

4/26/2021

DaisyBill receives a ‘please stop’ letter from PHS attorneys.

We see it as a vital part of our mission to ensure that workers’ compensation providers understand how slippery the world of network discounts can be. Whether it’s the blurred distinction between MPNs and PPOs, the opacity of discount leasing, or muddled execution timelines, discount dangers lurk.

For PHS to react so aggressively only drives the point home. We are guided accordingly.


DaisyBill helps providers obtain correct reimbursement for treating injured workers — quickly. Contact us to learn how we can help your practice

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