Scrubs & Suits: Mitigate the Impact of Silent PPOs

“Silent PPO” is the term used to describe when a non-contracted payer or plan administrator applies a contracted payer’s fee schedule to services rendered by a provider, without the provider’s prior knowledge or consent,” said NAB president Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I, CGS-P in a recent article.
Additionally, she gives readers several tips to reduce the blow to your practice’s bottom line:

  • Using a contracted network affiliated payer list, review each explanation of benefit and honor only authorized payer fee adjustments.
  • Request updated contracted network affiliated payer list every three to six months.
  • Employ “when in doubt, check it out” mentality by contacting the contracted payer network for updated affiliated payer information.
  • Be wary of “valid agreement language” used by non-contracted payers. Who is the valid agreement with—the provider or the contracted payer?
  • When contracting with new payers, stipulate that discounted rates will only be applied if patient steerage and provider promotion is employed.
  • Consider contracting directly with the non-contracted payer. By contracting directly, the provider should receive the benefits expected through network contracting (e.g., patient steerage and provider promotion).
  • Know your contract termination date(s), and inform the staff responsible for payment posting of termination date(s) to prevent ineligible discounts from being taken

Read the full article here.

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