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PPO discount taken on Work Comp Claims

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thatcuteblonde:
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:
What was the reason code / explanation on the EOB? that's a big cut.

Michele:
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.

Michele

thatcuteblonde:
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:

--- 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?
--- End quote ---

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?

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