Contributed by Karyn Reader, LCSW
Silent PPOs and a class action suit
Silent PPOs, such as Multi-Plan, Beech Street, Devon and others intrude into your fee arrangement with private pay patients. Brian Hufford, Esq., an attorney is trying to put together information from "providers" and patients that have been affected by these companies and pursue a class action suit. His fee would be a percentage of the damages if he wins the case. Below is a summary of what these companies do.
All of these silent PPOs are setting PPO rates for providers who do not believe that they ever agreed to accept discounts. The key is that a provider would only agree to discounted rates in exchange for having patients directed to them (i.e., to accept lower rates in exchange for higher volume). With these silent PPOs, however, the insurance companies are seeking to impose discounts but without actually directing patients to them, so the providers are not getting anything for their proposed agreement to accept discounts. It would be helpful to keep this issue out there and to try to get more information from as many providers as possible. We need that if a case is to be developed.
Big insurance companies sign on to these silent PPOs and suddenly, someone who has been getting full reimbursement on your fee is told that a much smaller amount is now allowed.
Cigna, United Health Care, Oxford and other major insurance companies search for these silent PPOs, which merge and put you on their membership list without your awareness. Suddenly the EOB states that you were not supposed to charge your fee to your patient. Often we do not even get that EOB, but the patient does, and the question arises as to whether you owe the patient money or whether their reimbursement will be less. Finding and resigning from these companies is essential, but is difficult and time consuming.
If you've had any such experiences, contact Brian Hufford, Esp at email@example.com. This would help with the class action suit. By the way, the suit will be on a national level, so tell your colleagues in other states as well.
As most of you probably have heard, Medicare rates have never been fully funded. This year they must have changed three times and take up a lot of time in Congress to be funded adequately. Presently, there has been a one month extension only. Unless funding is found, there will be a 23% cut in Medicare rates. This impacts what those of us who see Medicare patients will be paid, and greatly affects the number of providers willing to see Medicare patients at all. Given that the vast majority of people in this country have Medicare once they reach age 65, it is a huge problem to dissuade doctors, therapists, etc., from serving them due to inadequate pay. Contact your congressmen and let them know how essential it is to maintain Medicare rates!