Triton Healthcare Partners and Apricus (formerly Preferred Care Solutions) are collaborating with other Preferred Provider Organization (PPO) entities to hijack payments from doctors.

A recent Explanation of Review (EOR) shows Triton and its cabal of sidekicks (in our opinion, leeches on the workers’ comp system) taking huge chunks of revenue from one provider. First, Triton and its crony companies gorged themselves on a 30% PPO Reduction. And just for good measure, Triton & co. then licked the bowl clean with an inexplicable 2% “ECHO Service Fee.”  

The upshot: For treating an injured California worker, Triton paid this provider only 69% of the reimbursement due per California’s Official Medical Fee Schedule (OMFS) — which equals only 78% of what Medicare pays doctors for the same services.

California legislators know that the cost of delivering services to injured workers is far more than delivering services to Medicare patients. For exactly that reason, California established the OMFS to reimburse providers at commensurate rates — approximately 130% of Medicare reimbursements.

In theory, the OMFS reflects the added costs of delivering workers’ comp treatment; in practice, California allows these Pilfering Provider Organizations to feed on the employer dollars meant to cover the cost of restoring the health of their workers.

Providers (and legislators), do the math! On the back of an envelope, any provider can easily calculate that treating workers’ comp patients for 78% of what Medicare pays is untenable. Our advice to any provider contemplating workers’ comp is to carefully weigh the costs, as you may find that you are financially (and psychologically) way better off treating Medicare patients.

California employers, be advised. If you think the money you spend on workers’ comp coverage is paying for your employees’ care, think again. Your workers’ comp dollars are being siphoned off by third-party PPO “collaborations” — making revenue unstable for providers, driving doctors from the system, and leaving your workers with fewer and fewer options.

The only feasible way for doctors to end this widespread payment abuse is to immediately CANCEL all PPO contracts.

Bill Breakdown: Triton PPO Plunders Provider

The California Division of Workers’ Compensation (DWC) maintains several fee schedules for workers’ comp services. daisyBill software uses these fee schedule rates to calculate the exact amount owed to the provider for the treatment(s) billed. By providing the exact amount due per the applicable fee schedule, daisyBill software empowers doctors to both:

• Submit bills for the correct OMFS amounts, and
• Verify that claims administrators correctly reimbursed bills per the OMFS

Below is a bill that a provider submitted to Intact Insurance Specialty Solutions. The screenshot below demonstrates that the “Charges” for the services rendered equal the amounts owed under the “Expected Fee Schedule,” in this case the California Physician and Non-Physician Practitioner Fee Schedule.

The provider sent Intact Insurance a bill totaling $406.03, and the amount due per the California OMFS is also $406.03.

Triton — an entity heretofore unknown to us that describes itself as a “national PPO network and ancillary service solution” — sent the provider the EOR below. This Triton EOR reflects a massive “PPO Reduction” totaling $121.81, or 30% of the OMFS reimbursement owed.

Questions: What justifies this hefty PPO Reduction? What services did Triton provide to the patient or the employer worth 30% of the reimbursement owed to the provider?

Answers: For our part, we can find no possible justification for this or any PPO Reduction. Triton provided ZERO services to the injured worker and ZERO services to the employer. Triton simply claimed a portion of the revenue intended to pay for the worker’s treatment.

Triton and similar PPO entities are decimating workers' comp —  and somehow, California allows the carnage.

Triton Pays Rates = 80% Medicare Rates

For even more context, consider that Triton paid 20% less than the amount Medicare pays providers for the same services.

Triton’s PPO Reduction left the provider with $284.22. For the exact same procedure codes, on the same date of service at the same locality, Medicare pays $356.36. For treating this injured worker, Triton paid only 80% of the amount allowed by Medicare for the same services.

“ECHO Service Fee” Takes an Extra 2%

In addition to taking 30% of the provider’s OMFS reimbursement, Triton also assessed the provider an additional $5.66 “ECHO Service Fee.” But the provider's payment was via Automated Clearing House (ACH), so what is this “Service Fee” for?

Does Triton employ or own ECHO? Who knows? Triton took an additional $5.66 from this provider without bothering to offer any reason the provider owes either Triton or ECHO a 2% “Service Fee.”

Questions: In an industry where paper check or fee-free ACH payments are routine, what did Triton do to earn a 2% ECHO Service Fee? What can be done to stop this madness?

Answers: As far as we can tell, Triton did absolutely nothing to earn a 2% fee or any fees. Remember the days when PPOs took 5% of your revenue? Now PPOs take 30%.  A 2% service fee today means a 10% service fee tomorrow. Providers, please cancel these PPO Contracts.

The PPO Model: Making Workers’ Comp Unsustainable

Once Triton was done gorging, this provider was left with a grand total of $278.56, for a bill where $406.03 was owed according to the California OMFS. Again, that’s:

• 69% of OMFS Reimbursement
• 78% of Medicare Reimbursement

What is the point of a state-established fee schedule, if it’s only going to be undermined by barely-regulated, barely-understood private schemes to siphon provider revenue? Providers cannot furnish services to injured workers for reimbursements that are 22% below the amount allowed by Medicare.

A Cabal of Sidekick “Leeches”

We started this article announcing that Triton Healthcare Partners and Apricus (formerly Preferred Care Solutions) are “collaborating” with other PPO entities to strip providers of their reimbursements. From the EOR, at least 3 entities are involved in the pillage:

1. “Amer Choice Prov Netwrk WC”
2. Apricus (formerly PCS)
3. Triton Healthcare Partners

And by the way, the provider in question has no recollection of signing the PPO agreement with “Amer Choice Prov Netwrk WC,” as cited on the EOR.

Given the complexity and opacity of “collaborations” like Triton & co’s, providers can easily find themselves subject to mysterious — and significant — reductions like the one we’ve unpacked here.

Providers, listen up: California has NOT and is NOT coming to providers’ (or workers’ comp) rescue any time soon.

Individually, providers are at the mercy of these well-funded entities running laps around the laws, regulations, and rules of California workers’ comp. But together, by refusing to sign and canceling these contracts, providers can put PPOs and other sidekick parasites out of business.

Together, workers’ compensation providers hold all the power. Without providers, there is no treatment for injured workers. It is past time to say NO to this payment abuse.

daisyBill makes authorization, billing, and appeals easier, faster, better for the providers who treat injured workers. Reach out to learn how we can help your practice.

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