Practice Management Alert

Can you keep track of which payers you participate with? Some repricing companies are betting you can't and are cutting down on what they pay without giving you anything in return.

Unless you learn how to unmask these impostors, your office could be letting good money slip right through its A/R.

This scheme, dubbed the silent PPO, occurs when a payer has accessed your contract discount information and applied it to a claim for a patient who was not referred to your office as part of a PPO network. However, sometimes a payer can legitimately access a discount by joining an umbrella network. It takes some legwork to learn whether you're being scammed or if someone is using the network legitimately. If It Looks Like a Silent PPO To learn whether you're losing out on money you deserve, experts say, you must watch for these red flags when they're posting EOBs:

An EOB from a repricing company that states, "PPO discount applied" but doesn't name a specific PPO; or An EOB with a discount, but from a payer you don't participate with. If you post an EOB that lists a reduced payment, you should make sure the payer is a company you participate with. Jennifer Bever, MS, CHE, a consultant with Karen Zupko and Associates Inc., a practice management consulting and training firm in Chicago, counsels practices to use a contract summary grid containing all the pertinent information about your practice's current contracts. The grid is a primary resource for checking to make sure discounts are legitimate, she says.

You may also want to use your practice management system to keep track of discounts for you. Some systems have a built-in feature to track contracts and alert you when a nonparticipating payer discounts a claim, but others do not, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., in Lakewood, N.J. If your system doesn't have that feature, you can design some way to keep track of that information, she notes. In the past, Cobuzzi used two codes for each insurance company one that was alphanumeric to denote participating and one that was just numeric to denote nonparticipating.

Whether you track current contracts electronically or with a paper chart, you should be able to identify quickly whether the payer deserves a discount.

When you discover a discounted payment from a nonparticipating provider, it's time to become a detective. The following steps will help you learn what's happening and help you fight off scams. 1. When you find a suspicious EOB, put the check in a drawer and don't cash it, says Gil Weber, MBA, a practice management consultant in Davie, Fla. If you cash the check, [...]