Combating silent PPOs.

Abstract

A silent PPO is a contracting entity that negotiates discounts with providers but sells access to the discounts to other, nonrelated parties after services are provided to individuals covered by the nonrelated parties' insurance policies. Healthcare financial managers should be alert to the presence of silent PPOs when entering into contract negotiations. To combat silent PPOs, a two-pronged approach--prevention and detection--is advisable. Factors to consider include appropriate contract language stating that all clients with access to the discounts have a contract with the PPO, presence of the PPO's logo on a patient's insurance card, and the PPO's willingness to limit the number of providers in its network. Warning signs that indicate the presence of a silent PPO include a high volume of retroactive reclassifications, single employers taking discounts from multiple PPO networks, or payments for services provided to single individuals coming from multiple PPO networks.