Author Topic: PPO discount taken on Work Comp Claims  (Read 3179 times)

thatcuteblonde

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PPO discount taken on Work Comp Claims
« on: August 03, 2009, 03:29:48 PM »
Has anyone one else had this problem? I came across a ton of Workers Comp claims that were discounted through First Health, so even though the allowed amount for CPT code 27275 is $735.00 under the Illinois Work Comp Fee Schedule, we were paid $82.66. I know there was a law suit in regards to this but I came on board here a bit too late, so I'm hoping to appeal this. Does anyone have any suggestions, insight or experience with this type of scenario?


Thanks!

PMRNC

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Re: PPO discount taken on Work Comp Claims
« Reply #1 on: August 03, 2009, 03:44:26 PM »
What was the reason code / explanation on the EOB? that's a big cut.
Linda Walker
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Michele

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Re: PPO discount taken on Work Comp Claims
« Reply #2 on: August 04, 2009, 06:53:26 AM »
We have had this, but on a smaller scale.  Usually it's for an ov, the allowance for wc is $27.11 and the doc receives $23.06 stating "PPO discount".  When you call, after many attempts and being given lots of misinformation you find out it's because the dr pars with First Health, and somehow this wc carrier found a way to piggy back on the contract.  The only way to stop it is to write a letter stating the dr wants out of the First Health but I have found no successful way of backdating, or getting reimbursed for previously processed claims.

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thatcuteblonde

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Re: PPO discount taken on Work Comp Claims
« Reply #3 on: August 04, 2009, 09:41:18 AM »
We did send a certified letter insisting we be taken out immediately. Two years later this still hasn't been rectified. Even one of our providers who isn't in network with First Health had her claims discounted. Overall I'm looking at around $20,000.00 in unjustified discounts and unpaid claims. I guess I'm not sure how they were able to circumvent the rights we are afforded under the Work Comp regulations in our state. These claims were through AIG. I guess what I'm really trying to find out is whether or not this is legal?

PMRNC

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Re: PPO discount taken on Work Comp Claims
« Reply #4 on: August 04, 2009, 10:35:14 AM »
Quote
We did send a certified letter insisting we be taken out immediately. Two years later this still hasn't been rectified. Even one of our providers who isn't in network with First Health had her claims discounted. Overall I'm looking at around $20,000.00 in unjustified discounts and unpaid claims. I guess I'm not sure how they were able to circumvent the rights we are afforded under the Work Comp regulations in our state. These claims were through AIG. I guess what I'm really trying to find out is whether or not this is legal?

So First Health was the network and AIG was the carrier?  Which did you par with? Also sending a Letter may not have been enough, you have to get out the contract and look for the "opt out" clause/procedure and follow it. The contract would also most likely state that a confirmation of removal be sent to you. If procedure was not folllowed to opt out of the network you are considered participating until that's done. When you say "two years later this still hasn't been rectified" no one can really advise you one way or the other because we don't know what was done within those two years to be sure you met the "opt out" conditions. Some carriers have an opt out wait time.. (usually a year but I've seen carriers have a 2 year wait) that allows the provider the time to let patient's know.
Also you will want to find out IF AIG can piggy back off of the contract with First Health .. My guess is they can

So what I would do if I were you would be to get out the contract with First Health, Review the contract, and get up to snuff on all that was actually done to "opt out" and be sure that was done properly. If it was then your appeal will be based on the fact that you were NOT participating and send in your supporting documentation that follows the "opt out" procedure (letters, letter of confirmation from first health, etc).

I'm still a little confused on the large cut.. Are you absolutely sure there are no other reason codes on the EOB? From $735.00 to $82.66 is a VERY large cut and I'm scratching my head on that..  Have you actually CALLED the carrier, is there a chance they made a mistake?
Linda Walker
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thatcuteblonde

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Re: PPO discount taken on Work Comp Claims
« Reply #5 on: August 05, 2009, 11:31:54 AM »
I have found this same issue with several work comp carriers, including Liberty Mutual and Cambridge. After some research I've found they are considered Silent PPO's, which are set up as follows. The provider is par with Aetna, Aetna forms a subsidiary group called Aetna Work Comp where Work Comp Claims are paid at 100% of the Aetna contracted rate, Cambridge then becomes an 'affiliate' of Aetna entitling them to the same discount we have give patients with a PPO plan through Aetna. I have contacted First Health in an attempt to get a copy of our contract, however to no avail. After being transfered around several times, I got the woman in contracting's voicemail which states she will be out of the office for the next week and there was no forwarding number left.

I also contacted Aetna and spoke with a rep who said we were 'grandfathered in' or deemed in Alta Vista health vare which she stated was the specific contract language. I have placed a call to our attorney's office to find out how it's possible for them to do this but in the mean time, our current claims are all being discounted against our will. Unfortunately not a lot was done in the past and the inexperienced billers did not handle things correctly which has created a mess that's now approaching $100,000.00 in discounts just like the one I stated previously. We have work Comp Claims that are being paid at less than the medicare allowable stating 'PPO discount taken through Focus/Aetna.'

I also contacted the Illinois Work Comp Commission and they said any contract would take precidence. At this point, I'm not even sure if First Health EVER had a contract with our office and haven't been able to get ahold of anyone who could prove otherwise. I'm not really sure how to proceed but I do know that the discounts being taken are outrageous. Even on our facility fees we've gotten $100 on $1000.00 charges. They're literally raping us and even after getting out of First Health it's just being discounted under another group. Any thoughts?

PMRNC

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Re: PPO discount taken on Work Comp Claims
« Reply #6 on: August 05, 2009, 01:02:10 PM »
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I also contacted the Illinois Work Comp Commission and they said any contract would take precedence

That's correct.. And I don't know why the "silent ppo" didn't dawn on me until you mentioned it.  Your situation may or may NOT be legal depending on the actual contract: If the contract states the PPO has the right to lease out the network you will be S.O.L 

So my BEST advice would be to DEMAND the contract or review one if you have it. If the contract states the PPO may lease out to other networks there's not much you will be able to do. There is a case in Illinois I'm not sure has been settled but it's a class action suit against Travelers Insurance for Workers Comp claims and them using silent PPO. I believe it was Madison County, you can do a Google search and see if there is any information in there that might help. Bottom line you need the contract and the attorney should review it.
 
Linda Walker
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Pay_My_Claims

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Re: PPO discount taken on Work Comp Claims
« Reply #7 on: August 05, 2009, 01:34:39 PM »
Linda, can you be my attorney ???  ;D

PMRNC

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Re: PPO discount taken on Work Comp Claims
« Reply #8 on: August 05, 2009, 02:17:22 PM »
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Linda, can you be my attorney Huh  Grin

I think MY attorney would have a problem with that as well as your state Bar .. lol 

I'm only sorry I didn't have the silent ppo thing hit me until she mentioned it.. when I do the initial contract reviews with credentialing that is one of the things i scan the contract for, it's about 2 or 3 lines but it gives the PPO the right to lease to whoever they want to.  Now I have seen some where they will NAME the leased networks they lease to and I usually run it by the provider before it goes to his/her attorney, but the ones where it's a blanket release allowing them to lease to anyone at anytime, I send it back unsigned and have them modify it or remove it.  I do have to say I've only seen a few carriers do this for Workers Comp and MVA and that clause in the contract supersedes any state reg because it was disclosed.
Linda Walker
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