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PPO discount taken on Work Comp Claims

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thatcuteblonde:
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:

--- Quote ---I also contacted the Illinois Work Comp Commission and they said any contract would take precedence
--- End quote ---

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.
 

Pay_My_Claims:
Linda, can you be my attorney ???  ;D

PMRNC:

--- Quote ---Linda, can you be my attorney Huh  Grin
--- End quote ---

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.

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