Silent Payor Networks: The Physician Perspective

Silent Payor Networks: The Physician Perspective Chuck Neff Pinnacle Partners in Medicine TMGMA

Legitimate Payor Networks Defined • Contractually connects healthcare providers with payors who steer patients • In exchange for increased patient volume, providers give payors discounts on their billed charges • Legitimate payor networks advertise their contracted providers as part of their network via provider directories and on their websites

Legitimate Payor Network Process • Patient presents an ID card with the logo of the network(s) with whom the payor has contracted • The physician determines whether of not (s)he is contracted with the network(s) • Upon receipt of the EOB, the network contract used to reprice the claim matches the network on the patient’s ID card

Process Breakdowns • Payors are accessing discounts without physician contractual agreement • EOBs show discounts taken via networks not contracted with the physician nor listed as payors by the network • TPAs and payors are taking a different network discount for each line item on a claim • Lack of transparency by payor networks prevents physicians from determining accurate claim payment, therefore harming patient-physician relationship

Process Breakdowns • Employers are harmed because they were sold a network that does not really exist so they are offering their employees a false benefit • Patients are harmed by this fraudulent business practice places undue stress on the patient-physician relationship and because they become liable for larger than expected out-of-pocket payments • The community at-large is harmed because a falsehood is perpetuated through the employer and its employees

Possible Solutions • Require transparency of the entire contractual relationship and claims adjudication process. • Network should allow the Provider to terminate a Payor’s access to the discount upon Provider’s request. • Most physicians are offered a “take it or leave it” document purporting to be a contract between consenting parties when in fact it is non-negotiable • Silent payor activity should be considered a breach of contract • Contract law requires an offer and acceptance. With a silent PPO, there is no offer and no acceptance • Silent payor activity should be considered a fraudulent business practice

Silent Payor Networks: The Physician Perspective