Practice Management Alert

When you examine your EOBs, you may discover that the payer has illegally reduced your reimbursement using shady schemes such as the "silent PPO."

A silent PPO is an organization that you do not participate with, but that purchases a list of providers from your existing PPO and attempts to take reductions.

The silent PPO is "often the most difficult reimbursement scheme to detect," says Gil Weber, practice management consultant based in Davie, Fla.

Weber offers the following clues that will tell you if an indemnity insurer is applying a PPO discount to one of your claims:

1. A patient is not aware of the PPO on intake, lacks an ID card, never received a provider directory, or was not referred or steered to your office.

2. An EOB does not specifically identify the PPO whose discount is supposedly being accessed.

3. An EOB has the name of a bill-review repricing company or repricing software product on the top (e.g., Concentra Managed Care, PriceWell), or there is an indication that the bill was repriced or that a repricing analysis was performed.

4. An insurer cannot produce a plan summary or written confirmation that it has incentives in its plan design to direct patients to your facility.

Note: The next issue of Medical Office Billing and Collections Alert will include an in-depth article on tactics for fighting the silent PPO. $ $ $