As the PPO industry slowly transitions to developing a more efficient business model, from time to time we will encounter unusual and unfortunate circumstances that typically do not bode well for either the TPA or plan.
 

Case in point: a TPA client approached us recently, explaining that a provider submitted a claim for reimbursement through the PPO network that was denied because it did not have an authorization to perform the services. Six months later (and after stop loss coverage had lapsed) the authorization snaked in and the claim was approved-to the tune of over several hundred thousand dollars.  A demand by the provider for arbitration soon followed. The plan and TPA asked us what, if anything could be done?

Under the circumstances, absent any timeframe within which to submit claims for reimbursement, there was not a whole lot we could do to help. Most major PPO contracts only provide that if the claim is clean (and this case initially it was not) that payment must be made within 30 days REGARDLESS OF WHEN IT IS SUBMITTED!

A word to the wise, when negotiating PPO contracts - keep in mind that it does not benefit any interested party to jeopardize the financial integrity of the plan when some simple guidelines could be established to avoid the above dilemma.

The Phia Group, LLC has extensive experience in negotiating and handling PPO issues and can provide assistance in any capacity.

Our goal at The Phia Group is to reduce the cost of healthcare through innovative technologies, legal expertise, and focused, flexible customer service.  The following case is an example of how we put our words into action.

This case involves a two car auto accident in which a plan member was rear-ended by another driver. The medical expenses incurred by the member exceeded $50,000. The at-fault medical payment policy had only state mandated policy limits of $30,000; our member did not carry Underinsured/Uninsured Motorist coverage.

The member had retained an attorney to protect her interests. The attorney of record proposed a pro-rata share, with each party receiving a 1/3 of the policy limits. The Phia Group takes pride in the fact we know our clients and have a feel for their needs. The proposed offer was tabled and we began reviewing the viable options to determine how we could assist our client.  In reviewing the claims, we discovered a hospital charge submitted from a non-par provider which exceeded $50,000. We contacted the hospital and negotiated a 35% discount of the billed charges.

Based upon the Plan language provided by Phia Group it was expressed to the attorney the member's obligations and we would only accept two-third share of the proposed $30,000 resulting in the Plan receiving $20,000 as full and final settlement. The attorney reviewed the Plan language and agreed to the settlement. Through creative thinking and expertise, The Phia Group saved the $38,076.63 in soft savings above and beyond the actual recovery dollars.