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We specialize in helping medical providers identify and recover money lost to Managed Care Contract Abuse (MCCA). We currently represent individuals and class action plaintiffs who were victims of Silent PPOs in Florida and Massachusetts. What is a Silent PPO? Silent PPOs are illegal, fraudulent schemes
that every year take millions of dollars out of the pockets of physicians
and health care providers.
The term Silent PPO refers to the scheme
where insurers, who do not offer PPO policies, apply your contracted
PPO discount rates to bills for patients who are not PPO members. Insurers
who operate Silent PPOs are typically indemnity insurers, such as automobile
insurers and workmen’s compensation insurers, that have no way
of referring patients to you.
Medical providers join PPOs to increase
patient volume. Legitimate PPOs increase patient volume by entering
into agreements with Payors, most often group health insurers. These
group insurers offer PPO policies that contain steerage mechanisms to
in-network providers, such as lower co-payments, lower deductibles or
lower premiums. Also, legitimate Payors distribute provider directories
that identify the preferred providers in the network. These directories
are given to patients when they purchase their insurance and receive
their PPO member ID cards. In exchange for increased patient volume,
providers give legitimate Payors steep discounts on their bills, sometimes
as much as 50% off their usual charges.
That is not what happens with Silent PPOs.
Under a Silent PPO scheme, Payors who do not offer PPO policies obtain
the database of preferred provider rates from your PPO or from a middleman
called a “discount broker.” Then they apply those discounts
to your bills. You get nothing in return. In fact, it’s impossible
for you to get increased patient volume from such insurers because they
have no PPO policy, they provide no directories, and they give out no
PPO ID cards. The patient does not even know the name of the PPO whose
discounts were applied to the bill. As part of the Silent PPO scheme,
insurers try to pass off the discount as legitimate on Explanation of
Benefit forms.
The result? You lose a tremendous amount
of money — and, most likely, never discover that you have been defrauded.
The AMA estimates that medical providers lose tens of millions of dollars
per year based on the Silent PPO scheme. Do you know if you’ve
been victimized?
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 How a Silent PPO Scheme Works 1. Office Visit. A
patient chooses to treat with a certain medical provider. The patient
is not referred or steered to the provider by an insurer. The primary
type of insurance coverage responsible to pay the bill is a form of
indemnity insurance, such as automobile insurance, worker's compensation,
disability insurance or the out-of-network portion of a PPO policy.
2. The Insurance Claim. The
medical provider bills the insurance company based on their usual and customary
charge for the service provided.
3. The “Re-pricing” of Your Bill. The
patient’s insurance company receives your bill and does one of
two things. It either:
The discount broker searches for a PPO “hit”
by running your tax ID number through its database of PPO discounts.
After a successful “hit,” your bill is “re-priced”
based on the PPO discounts that were accessed.
4. The Deceptive EOB. After
applying the discount, the insurance company states on the EOB that
you agreed to reduce your bill based on your contract with the PPO.
This is usually FALSE because your preferred provider contract, if you
had one with that PPO, allowed only Payors with PPO policies or plans
to access your discounts.
5. The Write-Off. The medical provider accepts the insurer’s statement on the EOB and writes the discount off — never knowing that the discount was invalid. |
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