Your PPO Questions (So Far)

Your PPO Questions (So Far)

It’s almost time — we’re gearing up for our free live webinar on the financial danger Preferred Provider Organizations (PPOs) pose for practices that treat injured workers.

We’ve received a ton of valuable questions from readers, several of which we share below. These questions reveal what providers are going through due to PPOs, and the pitiful state of regulatory enforcement that leaves providers virtually unprotected from discount abuse.

Read on to see what providers and other workers’ comp professionals want to know, and what you can expect to learn.

PPO Questions from Workers’ Comp Professionals

If your practice treats injured workers, this webinar will show you exactly how detrimental PPO contracts can be — and how the effects of PPOs on practice revenue can “hide” in the data, even as reimbursements are reduced to below Medicare rates, as shown in the example bill and Medicare reimbursement calculation below.

Using real-world examples from actual practices, you’ll see where the revenue is really going. Spoiler alert: not to doctors.

Untangling the PPO mess is critical to both protecting individual practices, and reforming workers’ comp to better serve injured workers by keeping providers in the system. Legislators and regulators, take a close look at these questions, and ask yourself: what are we doing to protect the sustainability of the workers’ comp system from PPOs?

We’ll address the questions below, as well as those that come in before and during the webinar, on March 21.

Can work comp carriers deny us from seeing the patients if we disagree with their PPO discounts? — N.E.

We ask for copies of our signed PPO discount contract and never receive them.  How can we obtain this information? — A.L.

How is Anthem able to legally hold providers hostage? If we opt out of the PPO contract, we lose MPN status for SCIF and other administrators. — A.E.

Because we are contracted with Anthem Blue Cross, we suffer these PPO reductions across all payers. How can we get out of it without losing patients? — M.S.

How can we get paid OMFS rates? — S.C.

Is there a way to stop Eastern Alliance Insurance from forwarding bills to Homelink, which pays us at PPO rates when we do not have a contract? — G.S.

Triton Health and Paradigm: who are they? We bill the claims administrators and end up receiving payment from them. They're taking the PPO discounts as well. — I.C.

Why do insurers say fees were paid “based on the allowable contract rate?”  And why would there be two deductions, one ‘Reduction’ and one listed as ‘PPO savings?’  How can we identify which PPOs we are in contract with? — C.F.

I understand the issue with PPOs. It is a monopoly, as in you need more patients in your practice, you have to be a part of the PPOs.  — C.C. [Editor’s note: not exactly a question, but we understand! We’ll address the issues of Medical Provider Network (MPN) participation and patient steering during the webinar.]

We suffer daily from these PPO discounts. I have tried to argue it and they say it is because of our Anthem Blue Cross contract. We are finding that even out of network payers are using this tactic to reduce our payments too. In California, what can we do to fight this? — M.S.

How do we specifically drop the discount for work comp patients only? — L.L.

Just a thought! Can strength in numbers be harnessed for our benefit through daisyBill to fight ‘PPO plunder?’ There must be ways to combat these under the table/sleight of hand tactics used by PPOs to pillage medical providers. It is a known fact that medical providers are easy targets, as they spend most of their time providing medical care to injured workers and don't spend enough time sifting through alternative ways to counteract pillaging by PPOs to get reimbursed for the years of hard work required to obtain their medical degree. — S.C.

How can providers get out of PPO contracts without getting dropped from the MPN? — A.N.

In January Gallagher Bassett, Sedgwick, and Zurich began slashing my payments with a $70 PPO discount. Payments went from $ 123 (99213, WC002) to $68.00. I have no idea where this PPO discount came from. What can be done? — G.G.

This is a hospital billing question. When a payer reduces the bill down to the state fee schedule, they do not send 100% of billed charges to the PPO for proper contract application, especially when “lesser of” language is involved. How do you argue with the payer that 100% of the billed charges must be transmitted in order for the PPO rules to be applied correctly? — D.M.

How can we do away with Anthem selling PPO discounts to carriers? — B.J.

Knowledge is power, and we’re stronger together.

Workers’ comp can work for providers. daisyBill software, data, and expertise makes billing easier, faster, and less costly. Request a free demonstration below.


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