'Silent PPOs' and 'repricing' companies.When a contracting physician is unaware that a managed care organization (MCO MCO Managed care organization, see there ) is selling or renting its preferred provider organization pre·ferred provider organization n. Abbr. PPO A medical insurance plan in which members receive more coverage if they choose health care providers approved by or affiliated with the plan. (PPO PPO abbr. preferred provider organization PPO Managed care Preferred provider organization, see there Infectious disease Pleuropneumonia-like organism, see there ) network to a third party, the third party is acting as a "silent PPO A Silent PPO is an organization that sells a discounted rate for services from a physician, hospital or other health care provider without authorization to do so. The buyers of the discounted rate might be insurance companies, self insured employer health plans or another Silent ." The third party could be a third-party administrator, insurance broker, or a smaller PPO. The third party is able to take advantage of whatever discounts the MCO has negotiated with its physicians. Frequently, physicians become aware of such a situation only after they have provided services to patients who are not covered not covered Health care adjective Referring to a procedure, test or other health service to which a policy holder or insurance beneficiary is not entitled under the terms of the policy or payment system–eg, Medicare. Cf Covered. by the original PPO. After filing a claim with the patient's insurer, these physicians are paid less than the full amount, and the explanation of benefits (EOB EOB Explanation Of Benefits EOB End Of Block EOB Eye of the Beholder (game) EOB Executive Office Building (next to White House) EOB Electronic Order of Battle EOB Electricity Oversight Board ) shows that the discount was given to the original MCO PPO. Silent PPOs are successful largely because physicians in most practices do not have the resources to verify that a patient is enrolled in the PPO that is listed on the EOB accompanying the discounted reimbursement. This practice may or may not violate a contract, so physicians should pay particular attention to "all payer" clauses that may permit an MCO to sell or rent its negotiated discount. Physicians should investigate any instance in which payment is less than what was negotiated in a contract with a payer. (1) In a similar vein, "repricing Repricing To change the price of an asset. In derivatives, it sometimes refers to the exchange of options of with different strike prices. repricing " companies have developed a system that allows them to offer MCOs "custom networks" at significant discounts. If an MCO does not have the leverage to obtain discounts from providers, it can rent the network of a repricing company. There is one primary difference between a silent PPO situation and a repricing arrangement. In the latter circumstance, a physician actually enters into a contractual agreement with a repricing company and expressly allows the company's clients to rent medical services. In some cases, if a physician refuses to accept the repricing, the claim will be paid at the regular rate. Reference (1.) Isenberg SF. Expected payment variance. Ear Nose Throat J 2002; 81:829. Dr. Isenberg is an otolaryngologist in private practice in Indianapolis; sisenberg@good4docs.com |
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