Provider Warning: Prime Health Services (Part I)

April 19, 2021 9 min read

By: Catherine Montgomery

Provider Warning: Prime Health Services (Part I)

Recently, a provider made the unfortunate mistake of signing a Prime Health Services (PHS) Preferred Provider Agreement contract, commonly known as a PPO agreement. While not all PPO contracts are as rapacious as PHS’s, the manner in which PHS secured the provider’s signature raises some concerns — and warrants a strong warning to providers.

Providers, read this before signing any agreement that empowers the payer to reduce your reimbursement below Official Medical Fee Schedule (OMFS) rates.

We will continue this series of blog posts exploring the nefariousness of PHS’s Preferred Provider Agreement.

Confusing Network Propositions

PHS sent the provider two documents. One was an offer to work within a Medical Provider Network (MPN), nominally a group of providers to which employers send their injured workers. The other was a contract to affiliate with a Preferred Provider Organization (PPO), a group of providers who accept reduced reimbursements, theoretically in exchange for more patients.

Without speculating on PHS’s motives, we’re compelled to caution providers: be careful not to conflate MPN’s with PPO’s. Frankly, both can be terrible for a provider’s bottom line, depending on the contract. But in this case, PHS’s MPN was revealed to be a singularly hollow promise, complete with a fake website address and non-existent list of participants.

PHS’s MPN did produce one result, though: the provider signed onto the PPO, unaware of the distinction between the two.

If a PPO contracting organization were so inclined, it is easy to take advantage of a given provider’s confusion regarding network discount agreements. Both MPN’s and PPO’s involve wildly complex webs of payers, providers, and middle-people who stand to profit from how opaque these networks can be.

The Bait: The PHS MPN

PHS sent the provider the MPN “Continued Participation” document below, which explains that:

“For your practice to continue to treat workers’ compensation patients under these MPNs, you must comply with the MPN regulations at 8 CCR §9767.5.1 which require us to obtain the following acknowledgment from each practice that wishes to participate in our MPNs and our clients’ MPNs.”

There are two serious problems with this document:

The phrase “...you must comply with the MPN regulations at 8 CCR §9767.5.1 which require us to…” is a red flag. PHS is subject to the CCR requirement, not the provider. Arguably, this phrasing could be understood as an attempt to imply otherwise.
The URL listed on the document is invalid. In other words, the website that supposedly “allows you to see which MPNs are selected for your practice” and “opt-out” if desired doesn’t exist, as later confirmed by a PHS representative.

Worst of all, the MPN document came to the provider with another document: the unrelated PPO discount contract.

The Switch: The PHS PPO

In addition to sending the MPN acknowledgement, PHS also sent a Provider Participation Agreement for its PPO. This PPO contract has nothing to do with the PHS MPN, other than its being delivered concurrently with the MPN “Continued Participation” document.

However, the provider signed the PPO agreement, believing it was part of the MPN agreement. From the provider’s perspective, it was a classic bait & switch.

The PPO contract allows PHS to drastically reduce the provider’s reimbursements for treating injured workers by 30%. It allows PHS to transfer the 30% contract discount to all PHS clients. Before long, the provider saw bill after bill adjusted to 70% of OMFS rates.

And who are these “clients?” Read on for the (galling) answer.

PHS “Clients” = Bill Review Companies

On behalf of the provider, DaisyBill contacted Prime Health Services about the faulty MPN website link. A PHS representative explained there was no PHS MPN website. Instead, the representative furnished a list of “clients” that use the PHS PPO to discount reimbursements — all of which were bill review companies, not employers.

Let that sink in: when asked for a list of MPN participants, PHS instead gave us a list of bill review companies applying the PHS PPO discount on behalf of dozens of payers.

The PHS list includes bill review entities listed under “Client,” and payers under “Company.” The PHS representative explained that the list is meant to inform the provider of which PHS clients may help themselves to the 30% PPO discount, regardless of whether they send a single patient in the provider’s direction.

The list of “Clients” is reproduced in full below.

When any entity asks for a contracted discount, it is imperative to determine whether or not there is any real benefit to signing. All too often, a peek through the smoke and mirrors reveals the truth: some organizations are out to take providers for a ride to nowhere, at significant cost to practice revenue.

Client	Company
Amerisys
Bunch & Associates, Inc.	Employer's Insurance
Bunch & Associates, Inc.	Employer's Insurance
Bunch & Associates, Inc.	Salvation Army
Bunch & Associates, Inc.	Tractor Supply Corporation
CompIQ	Allied Managed Care
CompIQ	Arissa Cost Strategies
CompIQ	Definiti
CompIQ	ESIS
CompIQ	Lien On Me, Inc.
CompIQ	MEDEX
CompPoint Managed Care, Inc.	DEKALB COUNTY SCHOOL SYSTEM
Comprehensive Cost Solutions - 2CS
Comprehensive Cost Solutions - 2CS	Baldwin Park Unified School District
Comprehensive Cost Solutions - 2CS	Benchmark Insurance Company - CompStar
Comprehensive Cost Solutions - 2CS	City of Eureka
Comprehensive Cost Solutions - 2CS	Foster Farms
Comprehensive Cost Solutions - 2CS	Garden Grove Unified School District
Comprehensive Cost Solutions - 2CS	JT2 Integrated Resources
Comprehensive Cost Solutions - 2CS	North Bay Schools Insurance Authority
Comprehensive Cost Solutions - 2CS	Redwood Empire Schools’ Insurance Group
Comprehensive Cost Solutions - 2CS	REMIF
Comprehensive Cost Solutions - 2CS	Schools Insurance Authority
Comprehensive Cost Solutions - 2CS	WIC
CompStar Systems, Inc.	City of Fayetteville in North Carolina
Conduent	Accident Fund Insurance Co of America
Conduent	AdminSure
Conduent	Advantage WC Services
Conduent	Allied Managed Care
Conduent	Care Logic
Conduent	CareSolutions
Conduent	CCMSI
Conduent	Charles Taylor
Conduent	CNA Insurance
Conduent	Definiti
Conduent	Employers Choice
Conduent	Employers Medical Network
Conduent	Hartford
Conduent	Hoover Rehabilitation, Inc.
Conduent	Injury Care of Nevada
Conduent	Marquee Managed Care
Conduent	NASSCO
Conduent	PMA
Conduent	ReviewMed
Conduent	Sedgwick
Conduent	Tribal First
Conduent	Wal-Mart
Conduent	Werner Enterprises
David Whiteside Consulting Solutions, Inc.	Trilogy Personnel & Land Management
EK Health Direct	Charles Taylor
EK Health Direct	TRISTAR
Equian	AC TRANSIT
Equian	CB01
Equian	CB05
Equian	COUNTY OF ORANGE
Equian	CSAC EXCESS INSURANCE AUTHORITY
Equian	Generations
Equian	GENEX Services
Equian	NCCSIF WC
Equian	NONPROFITS UNITED WCG
Equian	Parker Hannifin Corporation
Equian	SACRAMENTO METRO FIRE WC
Equian	SD UNIFIED SCHOOL DISTRICT
Equian	SEDGWICK CMS
Equian	SPECIAL DISTRICT RISK MGMT WC
Equian	STATE OF CA IHSS
Equian	TokioCA
Equian	US Administrators
Gallagher Bassett Services, Inc.
Integra Group
Intelligent Medical Solutions	BURLINGTON
Intelligent Medical Solutions	C&S WHOLESALE
Intelligent Medical Solutions	CHOC
Intelligent Medical Solutions	ESPARZA ENTERPRISES
Intelligent Medical Solutions	FINISH LINE SELF INSURANCE GRP
Intelligent Medical Solutions	GENERATIONS HEALTHCARE
Intelligent Medical Solutions	HEALTHCARE SERVICES GROUP
Intelligent Medical Solutions	HOAG HOSPITAL
Intelligent Medical Solutions	LOS ANGELES JEWISH HOME
Intelligent Medical Solutions	MERCHANTS BUILDING MAINTENANCE
Intelligent Medical Solutions	MERCURY INS.
Intelligent Medical Solutions	METHODIST HOSPITAL S.C.
Intelligent Medical Solutions	MONTEREY SALINAS TRANSIT
Intelligent Medical Solutions	NATIONAL RETAIL SYSTEMS
Intelligent Medical Solutions	OMNITRANS
Intelligent Medical Solutions	PACIFIC RISK MANAGEMENT
Intelligent Medical Solutions	PACIFIC RISK MANAGEMENT - SI
Intelligent Medical Solutions	POSTTIME
Intelligent Medical Solutions	REDONDO BEACH UNIFIED SCHOOL DISTRICT
Intelligent Medical Solutions	RIVERSIDE TRANSIT AGENCY
Intelligent Medical Solutions	SAN ANTONIO HOSPITAL
Intelligent Medical Solutions	SIF
Intelligent Medical Solutions	TRM MANUFACTURING
Intelligent Medical Solutions	UNINSURED EMPLOYERS FUND - LA
Intelligent Medical Solutions	UNINSURED EMPLOYERS FUND- OAK
Intelligent Medical Solutions	UPLAND UNIFIED SCHOOL DISTRICT
ManageWare
ManageWare	Beta Healthcare Group
ManageWare	CCCSIG
ManageWare	InterMed
MCMC	AC TRANSIT
MCMC	ADVENTIST HEALTH
MCMC	ALSCO, INC
MCMC	AMERICAN EQUITY RISK SERVICES LLC
MCMC	AMETROS FINANCIAL CORPORATION
MCMC	ARCHDIOCESE LOS ANGELES
MCMC	ASCIP
MCMC	C.S.R.M.A. W/C
MCMC	CINCINNATI INSURANCE - WC MASTER
MCMC	CITY OF ALAMEDA
MCMC	CITY OF MILPITAS
MCMC	CITY OF MOUNTAIN VIEW
MCMC	CITY OF PALO ALTO
MCMC	CITY OF REDWOOD CITY
MCMC	CITY OF RIVERSIDE
MCMC	CITY OF VALLEJO
MCMC	CITY OF WALNUT CREEK
MCMC	Clovis Unified Sch Dis
MCMC	COMMONWEALTH GARNET GRP CAPTIV
MCMC	COUNTY OF ORANGE
MCMC	COUNTY OF SAN BERNARDINO
MCMC	COUNTY OF VENTURA
MCMC	CSAC EXCESS INSURANCE AUTHORITY
MCMC	CSRM JPA
MCMC	DOWNEY UNIFIED SCHOOL DISTRICT
MCMC	EL DORADO COUNTY
MCMC	ENSIGN GROUP
MCMC	ENTERPRISE RENT A CAR
MCMC	ESKATON PROPERTIES, INC. W/C
MCMC	FORTIS INSURANCE
MCMC	FULLERTON SCHOOL DISTRICT
MCMC	GENEX Services
MCMC	HUDSON - WC
MCMC	JACKSON RANCHERIA - WC
MCMC	LOS RIOS CCD
MCMC	LWP-ARCH/MPN
MCMC	LWP-CITY OF SANTA ROSA
MCMC	LWP-NEW YORK MARINE & GENERAL
MCMC	LWP-PARSAC
MCMC	MARIN SCHOOLS INS. AUTH. W/C
MCMC	MONTEBELLO U.S.D.
MCMC	NAPA COUNTY W/C
MCMC	NATIONAL INTERSTATE INSURANCE - WC
MCMC	NAVIGATOR CAPTIVE ARCH
MCMC	NCCSIF W/C
MCMC	NONPROFITS UNITED WCG
MCMC	ONE BEACON INSURANCE COMPANY
MCMC	ONEX YORK HOLDINGS CORPORATION
MCMC	PARAGON AUTO DEALERS - ARCH
MCMC	PERALTA COMMUNITY COLLEGE
MCMC	PROCENTURY INSURANCE COMPANY
MCMC	RESTAURANT FRANCHISE CAPTIVE PROGRAM
MCMC	RIVERSIDE COMMUNITY COLLEGE
MCMC	RP AUTOMOTIVE, INC.
MCMC	SACRAMENTO METRO FIRE W/C
MCMC	SAN JUAN USD
MCMC	SD UNIFIED SCHOOL DISTRICT
MCMC	SEDGWICK CMS
MCMC	SPECIAL DISTRICT RISK MGMT WC
MCMC	STAR INSURANCE COMPANY - CA
MCMC	STARR INDEMNITY WC PROGRAM
MCMC	STATE NATIONAL
MCMC	STATE OF CA - IHSS
MCMC	STOCKTON USD - WC
MCMC	THE AMERICAN EQUITY UNDERWRITERS INC
MCMC	TULE RIVER TRIBAL COUNCIL - WC
MCMC	TV - WC
MCMC	VANLINER INSURANCE COMPANY - WC
MCMC	VIEJAS - WC
MCMC	WHITTIER AREA S.I.A.
Medata, Inc.	Arrowpoint Insurance
Medata, Inc.	Berkshire Hathaway
Medata, Inc.	Berkshire Hathaway Homestate Companies
Medata, Inc.	Berkshire MPN
Medata, Inc.	CIGA
Medata, Inc.	City of Long Beach
Medata, Inc.	City of Long Beach CA MPN
Medata, Inc.	CITYSD
Medata, Inc.	Hanover Insurance Group
Medata, Inc.	MEDATA
Medata, Inc.	OMNG
Medata, Inc.	SEDGWICKWC
Medata, Inc.	State of Wyoming
Medata, Inc.	TRISTAR Managed Care
Medata, Inc.	Warner Brothers
Mitchell - Smart Advisor	Aon eSolutions
Mitchell - Smart Advisor	Aon eSolutions - Self-Insured Schools of CA
Mitchell - Smart Advisor	Berkley Risk
Mitchell - Smart Advisor	Broadspire
Mitchell - Smart Advisor	California Joint Powers Insurance Authority
Mitchell - Smart Advisor	CCS Holdings
Mitchell - Smart Advisor	Church Mutual Insurance Company
Mitchell - Smart Advisor	CIRMA
Mitchell - Smart Advisor	CopperPointe
Mitchell - Smart Advisor	EK Health
Mitchell - Smart Advisor	FairPay
Mitchell - Smart Advisor	Farmers Insurance
Mitchell - Smart Advisor	Federated Mutual Insurance
Mitchell - Smart Advisor	FutureCare
Mitchell - Smart Advisor	GAB MedInsights
Mitchell - Smart Advisor	Genex
Mitchell - Smart Advisor	Great American Insurance Company
Mitchell - Smart Advisor	Guard Insurance
Mitchell - Smart Advisor	Innovative Claims Strategies
Mitchell - Smart Advisor	Insurance Company of the West
Mitchell - Smart Advisor	Keenan
Mitchell - Smart Advisor	Key Risk Management
Mitchell - Smart Advisor	Paladin Managed Care Services
Mitchell - Smart Advisor	Paradigm Management Services
Mitchell - Smart Advisor	Reny Company
Mitchell - Smart Advisor	Sentry Insurance
Mitchell - Smart Advisor	The CompTech Group
Mitchell - Smart Advisor	Workers Compensation Fund
Mitchell - Smart Advisor	Zenith Insurance Company and ZIC Insurance Company
Mitchell - Smart Advisor	Zurich North America
Paradigm	ABMINDUSTR
Paradigm	ALLEGIS
Paradigm	ALSCO, INC
Paradigm	ARCHDIOCESE LOS ANGELES
Paradigm	ARGO INSURANCE COMPANY
Paradigm	ARGONAUT INSURANCE COMPANY
Paradigm	ARROWOOD INDEMNITY
Paradigm	ASCIP
Paradigm	ATHENS ADMINISTRATORS
Paradigm	BARONA - WC
Paradigm	BERKSHIRE HATHAWAY
Paradigm	BROADSPIRE
Paradigm	C C M S I
Paradigm	CACHE CREEK - WC
Paradigm	CAPRI WORKERS COMP.
Paradigm	CCS CLAIM SYSTEM
Paradigm	CJPIA
Paradigm	CNA
Paradigm	COMPMANAGEMENT
Paradigm	COUNTY OF ORANGE
Paradigm	CSAC EXCESS INSURANCE AUTHORITY
Paradigm	CSRM JPA
Paradigm	DOWNEY UNIFIED SCHOOL DISTRICT
Paradigm	ENSIGN GROUP
Paradigm	ESIS
Paradigm	FARMERS INSURANCE
Paradigm	FORSTER-TRIBAL
Paradigm	FULLERTON SCHOOL DISTRICT
Paradigm	GALLAGHER BASSETT SERVICES INC
Paradigm	GARDEN GROVE UNIFIED SCHOOL DISTRICT
Paradigm	GREAT AMERICAN INSURANCE GROUP
Paradigm	HANOVER INSURANCE GROUP
Paradigm	HUDSON - WC
Paradigm	INNOVATIVE CLAIM STRATEGIES
Paradigm	LACOE/YORK RISK SERVICES
Paradigm	MARRIOTT CLAIMS SERVICES
Paradigm	MONTEBELLO U.S.D.
Paradigm	MURPHY & BEANE
Paradigm	NATIONAL INTERSTATE INSURANCE - WC
Paradigm	NATIONWIDE AGRI FARM
Paradigm	NATIONWIDE AGRIBUSINESS INSURANCE CO
Paradigm	NCCSIF W/C
Paradigm	NEXT LEVEL ADMINISTRATORS
Paradigm	NONPROFITS UNITED WCG
Paradigm	OASIS
Paradigm	ONEBEACON INSURANCE GROUP
Paradigm	PALA CASINO - WC
Paradigm	PALADIN
Paradigm	PECHANGA - WC
Paradigm	RIVERSIDE COMMUNITY COLLEGE
Paradigm	RP AUTOMOTIVE, INC.
Paradigm	SD UNIFIED SCHOOL DISTRICT
Paradigm	SEDGWICK
Paradigm	SHARPHEALT
Paradigm	SOBOBA ENTERPRISES - WC
Paradigm	SPECIAL DISTRICT RISK MGMT WC
Paradigm	STAR INSURANCE COMPANY - CA
Paradigm	STATE NATIONAL
Paradigm	STATE OF CA - IHSS
Paradigm	SUTTER HEALTH WORKERS COMP
Paradigm	SYCUAN - WC
Paradigm	THE ARC OF SAN DIEGO - WC
Paradigm	THE INS CO OF THE STATE OF PA
Paradigm	TRISTAR MANAGED CARE
Paradigm	TV - WC
Paradigm	VANLINER INSURANCE COMPANY - WC
Paradigm	VIEJAS - WC
Paradigm	WHITTIER AREA S.I.A.
Paradigm	ZURICH NORTH AMERICA
Rising Medical
Signature Networks PLUS	LWP Claims Solutions, Inc.
Zelis	GCIWCCAL
Zelis	GCIWCMCMC

DaisyBill offers workers’ comp billing software to ensure fast, accurate payment and easy appeals. Contact us to see how much your office can save.

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