Silent PPO --> RE: Re: Multiplan - Pay you less quicker

[Guest guest]

I am still confused, though, how I got in touch with Multiplan. As far as I

remember, I

billed one of the major insurance providers (BC/BS or First Choice) and I then

got a letter

that sounded like " if you want to get paid at all, sign this letter and you are

contracted

with Multiplan " . I assume I can easily opt out again of Multiplan but can they

force me to

sign up with them in order to get paid? Thinking about it, I believe it was one

of those

union insurances through First Choice that awarded me the Multiplan letter.

Can someone explain to me whether I really need to accept Multiplan in order to

bill these

First Choice union insurances or will it simply take longer to get paid but

reimbursement

will be higher?

Thanks, Marius

>

> As an education for us all -- here is what a Silent PPO is...

>

> This article is the most in depth...

>

> http://findarticles.com/p/articles/mi_m3257/is_7_57/ai_105501126/

>

> Tactics for thwarting silent PPO activity - Managed Care - a discussion of

> silent PPO payer arrangements for the health care industry

> =======================

>

> http://managedhealthcareexecutive.modernmedicine.com/mhe/article/articleDeta

> il.jsp?id=329908

>

> A silent PPO often is described as an organization that functions as a

> network of providers, but the discounts it takes with respect to medical

> claims may be without the knowledge or contractual consent of some of the

> network providers. Thus, the availability of the discount with respect to a

> particular medical claim depends on the legitimacy of the relationship

> between payer and provider and whether the payer has appropriate access to

> the discounts.

>

> snip/snip

>

> http://en.wikipedia.org/wiki/Silent_PPO

>

> A Silent PPO is an organization that accesses a discounted rate for services

> from a physician, hospital or other health care provider without direct

> authorization from the provider to do so.

>

> Generally, insuring <outbind://369/wiki/Insurer> entities may negotiate

> contracts with the healthcare provider, with a defined set of reimbursement

> values for the work performed by the provider. These rates may entail a

> significant discount from the amount the provider would charge an uninsured

> patient. For a given provider, the amount of discount varies between

> different insuring entities, and a separate contract is negotiated with each

> entity.

>

> Silent PPOs create agreements with insuring entities, allowing buyers into

> the Silent PPO to access the terms of the lowest discounted rate available.

> Patients (and other insuring entities who are members of the Silent PPO) may

> then access the lowest discounted rate of the healthcare provider, even

> though the patient is not directly a member of the plan contracted to the

> healthcare provider.

>

> The members of the Silent PPO might be insurance companies, self insured

> employer health plans or another Silent PPO. The Silent PPO could also be a

> middle man and resell their created network of healthcare providers.

>

> There are medical organizations which disagree with or dislike the concept

> of Silent PPOs. [1] <outbind://369/#cite_note-0> The problem as advocated

> is that when the physician negotiated the discount, they intended to give it

> only in exchange for referrals from members of the insurer - where a patient

> is given some advance incentive to choose them. Silent PPOs typically do not

> make referrals, but provide access to the discount after the service was

> rendered. Additionally, providers argue that had the patient not entered via

> a back-door arrangement, they would not have been given the discount applied

> to the contract. Thus, the provider loses money from the amount that would

> have been charged.

>

>

> [edit <outbind://369/w/index.php?title=Silent_PPO & action=edit & section=1>

> ]External links

>

>

> * Article in Healthcare Financial Management

> <http://findarticles.com/p/articles/mi_m3257/is_7_57/ai_105501126/>

> * Article <http://library.findlaw.com/2000/Oct/12/127454.html> by

> B. reproduced in in FindLaw

> * Article in June, 2006 issue of Managed Healthcare

> <http://www.managedhealthcareexecutive.com/mhe/article/articleDetail.jsp?id=

> 329908> Executive

>

>

>

> http://www.texmed.org/Template.aspx?id=5495

>

>

>

> Silent PPOs/Rental Networks

>

>

>

> _____

>

> When a physician contracts to join a health plan network, he or she agrees

> to accept a discounted rate in return for the plan steering patients into

> his or her practice through a listing in the health plan's directory.

>

> However, this discounted rate has been highjacked through a deceptive market

> practice called a " silent PPO " or " rental network. " A silent PPO/rental

> network is neither insurance nor a health care payment plan offered by a

> health plan to its clients. Silent PPO/rental networks are not regulated and

> create a huge obstacle to heath care transparency.

>

> A silent PPO/rental network generally takes no financial risk. The network

> " shops " around to find the lowest rates a physician has agreed to with any

> insurer, then " rents " that discounted rate to another entity without the

> physician's knowledge or permission. Fourteen states have laws to prohibit

> these arrangements.

>

> Patients also may suffer financially when the discount applied to their

> medical treatment is based inappropriately on the lowest contracted rate of

> a silent PPO/rental network. The patient may have to pay more toward the

> unpaid balance and incur higher coinsurance.

>

> Silent PPO/rental networks provide no benefit to physician practices or

> their patients. Physicians may become wary of granting discounts under their

> existing contracts or are forced to increase their existing contracted rates

> to offset losses from these unethical manipulations.

>

>

> Medicine's Agenda

>

>

> * Support legislation to regulate how a physician's contract rate is

> sold, leased, or shared among health plans.

> * Support legislation that will ensure the physician's right of action

> against anyone who improperly accesses their price discount.

> * Continue to encourage the Texas Department of Insurance to enforce

> current state insurance laws to alleviate this deceptive trade practice.

>

>

>

>

>

> Last Published: 1/23/2008

>

>

>

> Locke, MD

>

[Guest guest]

From Drain,

I got a letter like that as well. I called them and told them I would not consider taking less than the amount I billed and asked the phone call recipient if their employer discounted their salery, and whether they would accept it if such a discount was offered.

I never recieved such a letter again. I also got paid. I believe they figured "nothing ventured, nothing gained." If I had not gotten paid, I would have contacted the patient about the process.

Joanne Holland