Organize your contracts to eliminate silent PPOs

Whether you’ve just begun working at a healthcare organization or you’ve served as an administrator for many years, one of the most daunting challenges you’re likely to face is the forced reduction in reimbursement that results from silent PPO arrangements.

Physician practices are commonly victimized by silent PPOs when they treat patients out-of-network who are traveling, unable to visit their regular physician, or simply prefer a non-network provider. Typically, practices charge these patients the copay indicated on their insurance card—which may bear an unfamiliar logo—and expect to receive a portion of their usual fee from the health plan, with the right to balance-bill the patient. It can be quite a shock for practices to receive an explanation of benefits (EOB) providing them the same discounted rate they’ve negotiated with the local PPO.