Provider Warning: Prime Health Services (Part I)

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:

  1. 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.
  2. 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


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