Ask what caused the injury or illness. Confirm the type of insurance coverage your patient has under the circumstances. Determine which insurer is primary. Ask to see the patient’s insurance card for any and all insurance that may apply. Ask the patient if he or she is a member of any PPOs for any indemnity insurers. For example, if it is an auto accident, ask to see any ID cards from the automobile insurer and ask whether the patient is a member in an auto PPO. Copy both sides of the patient’s card. For all indemnity insurers, call to ask if the insurer offers the patient a PPO plan or policy and, if so, what the in-network and out-of-network requirements are. Check to see if you have a contract with that PPO.

Step #1: Know the Contents of Your PPO Contracts. Examine all your PPO contracts and the payor lists for each contract. See if there is room in those contracts for payors who do not offer preferred provider plans or policies to gain access to your discounts. If the nine terms discussed above are not in your PPO contract, you’re leaving yourself open to problems.

Step #2: Scrutinize All EOBs With PPO Discounts. Beware of the following red flags: (1) the insurer taking the discount is an automobile insurer or a workmen’s compensation insurer; (2) failure to name the PPO whose discount was accessed; (3) you have no PPO agreement with the PPO indicated; (4) the PPO discount is indicated on the check but not on the EOB; (5) the PPO is identified but you terminated the contract a while ago; (6) the EOB comes on a bill re-pricing company’s letterhead, rather than the insurer’s letterhead, and references the bill re-pricing company’s agreement with a PPO, rather than the insurer’s agreement with the PPO.

Step #3: Cross-check the EOB Against Your PPO Contract for that PPO. Check your contract to see if the payor is listed and what the contract requires.

Step #4: Cross-check the EOB Against the Insurance Information You Received From the Patient. When you questioned the patient at the time of intake, if the patient did not mention the PPO indicated on the EOB, that should be a red flag. For all suspect EOBs, contact the payor and ask if they offer a PPO policy or plan with in-network and out-of network features. Also, ask if the patient bought a PPO policy and whether the Payor has an agreement with your facility to discount your bills. Ask for a letter confirming both of these in writing.

Step #5: Contact the PPO and the Payor to Discuss the Discrepancy. If the PPO participated in the illegal discount, perhaps by selling the information to an improper payor, they may work with you to settle the claim with the payor. You can also make an oral or written demand on the payor for payment of the discounted amount. Don’t hold your breath for payment.

Step #6: Hire an Experienced Health Care Law Firm to Conduct a Mini-audit of Your EOBs and to Recoup Silent PPO Discounts. From our experience, the most effective way — and often the only way — to force payors to repay illegal and fraudulent discounts is to file a lawsuit, either on behalf of one medical provider by aggregating discounts into one lawsuit or as a class action. If the court certifies a class action, other medical providers may benefit by having their discounts repaid.