Beware: pirates are attempting to steal your insurance checks!

If you have recently opened the mail only to realize that you seem to be a “participating provider” with insurance companies that you never heard of, you are certainly not alone.  While it may seem silly to complain about being paid, the fact is that you are paid a contracted rate (which is sure to be less than your billed amount) for a contract that never existed. In other words, the payer has given you a “Wrongful Discount” because you never agreed to a discount in the first place!

This phenomenon – known as a “Silent PPO” – is just one of the latest in third party payer’s bag of pirate tricks aimed at reducing your payments.  Unfortunately, it is becoming an increasingly common occurrence in the field of medical billing.  (Yes, that means that it’s not just the chiropractors that are being picked on!)

This generally occurs in one of several ways:

1)     The Silent PPO can be a third party payer that is attempting to pay an out of network provider (that’s you) for a claim for their beneficiary (your patient).  Since they don’t actually have you locked in to contractually accept their discounted rate, the Silent PPO conveniently acts as if you have a contract and processes your claim according to the in-network rate.  Technically, there’s nothing very silent about this, since they simply paid your claim incorrectly.  And certainly, it is possible that this claim was paid in error at the lower, contracted rate.  Unfortunately, the frequency at which this occurs is alarmingly common and makes one suspect of how these errors can be so routine.  Additionally, since doctors often receive checks that batch groups of claims together in one lump sum, it is entirely possible that this “error” goes missed and with it, you have been paid less than you deserve and effectively, the PPO has received a “silent” discount from you.

2)    The second scenario is a variation of the first where the PPO actually pays you correctly, but processes the claim as in-network thereby “obligating” you to accept a contractual write-off that prohibits you from balance billing your patient.  Again, since there is no contract, this is incorrect and the payer is attempting to force you toward accepting a discount that you didn’t agree to, this time on behalf of your patient.

3)    Silent PPOs can also “attach” themselves to an existing contract that you have with a carrier. The language in your contracts may allow the payer to act as a broker reselling your contract with other partners. If your contract was not well negotiated, you are now taking reduced payments from multiple carriers.

Here’s how to stop this pesky PPO pilfering:

• Protect your practice by asking for specific language added to your contract stating that you get final selection of who you contract
• Insist that you must be notified in writing every time a new carrier is added to the “network” or to affect your contract.
• Negotiate the ability to opt out of any plan you choose not to participate with. By asking for this option you protect yourself proactively instead of always having to react. This also allows for you to make a listing of healthplans you are actually participating with and arms your staff with the knowledge of who you are contracted with so that they know the correct amounts to collect at the time of service.
• Appeal any claims that were incorrectly processed as if you were a network provider.  If you would like examples of letters to use for situation #1 and 2 mentioned above, consider purchasing our Wrongful Discount Letter Templates.
• For dozens of template letters that can be used for a variety of payment situations, denials, appeals, etc – you may be interested in the Chiropractic Appeals Toolkit (the Wrongful Discount Letters are included in the toolkit).

Get paid for the good work that you do!

Tom