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Tip of the month: Alter current procedures to reduce silent PPO activity

Managed Care Weekly Advisor, March 21, 2007

Silent PPOs, as their name indicates, can be difficult to identify. To avoid falling prey to these sneaky imposters-and correct the situation if you do-follow these steps:

  • Begin with audits. Sort out individual plans and their contracted payers' payment practices by auditing samples of the organizations' explanations of benefits (EOB). The PPO's name/identification number should match that found on the patient's identification card. The payer listed on the EOB should appear on the list of payers belonging to the PPO.

  • Tackle silent PPO issues in your contract. Attach a complete payer list to the contract and require the plan to provide a notice of changes to the list. Include a provision that requires forfeiture of all discounts that fail to comply with the PPO agreement.

  • Implement a process. Look at your patient accounting processes and add steps that will help identify unauthorized discounts.