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As one year comes to a close and a new one begins, many providers are crunching numbers, pouring over
billing reports, and finalizing projections for their budget. One of the main questions we get
from practice owners this time of year, is "How many patients have I seen through
my PREFERRED contracts?" The answer lies, at
least in part, in what I am now referring to as “THE MISSING LINK"
THE MISSING LINK = the PPO/Network affiliation. First, you, the provider, must
understand that the PPO network reflected on each Explanation of Benefit patient receives (EOB) is often
different from the actual payor of each claim (see sample spreadsheet below). For
example, by contracting with PHCS (a PPO who does not pay claims), you become a participating
provider for 300+ insurance carriers and administrators who are “clients” under PHCS,
who actually pay the claim, such as Fortis, John Alden & Zenith.
Next, because claims do not route through PREFERRED, we do not track
patient data. Therefore, it is critical for providers to learn how to track PPO
affiliations within their billing or practice management system, and to understand not
only which contracts they have, but how they are contracted (it could affect
their reimbursement), particularly as they most likely also have independent healthplan
contracts, or may be contracted through a source other than PREFERRED.
Most software systems have extra fields which you can designate for your own purposes. If your
system has that flexibility, consider the following “crash course” of steps which
you might consider taking, to tackle PPO/network tracking.*
Step One:
- Understand the difference between a PPO and the actual Payor of the claim
- PPO: builds a network of providers willing to take discounts (e.g. PHCS,
Beech Street, First Health)
- Payor: pays the claim (e.g. Fortis, Zenith Administrators, John Alden, or employers such as Walmart)
- Note: Sometimes the payor and the PPO are one and the same (e.g. Blue Cross, UHC,
PacifiCare, etc.)
Step Two:
- In your billing system, label one of the empty fields "PPO/network", and
another “How Contracted”
Step Three:
- Upon receipt of each EOB, record the PPO/network entity which applied the discount
along with the rest of the claims data. You’ll need to stay on top of which
contracts you sign, and how you are contracted.
- EXAMPLE: (Obviously you will record more information. The emphasis here is on
the MISSING LINK, which is the PPO/Network name from the EOB):
| New Patient Name |
New Patient DOB |
Referral Source |
Insured's Name |
Insured's SSN |
Employer |
Payor/Insurance Carrier |
PPO/Network Name from EOB |
How are we contracted? |
| John Doe |
4/5/65 |
Dr. Jones |
John Doe |
555-55-555 |
ABC Video |
Fortis |
PHCS |
PREFERRED |
| Susie Smith |
12/10/88 |
Dr. Hart |
George Smith |
000-00-0000 |
Alliance Laundry Systems |
Wassau Benefits Inc. |
Beech Street |
PREFERRED |
| Lisa Lynn |
1/1/77 |
Case Mgr PacifiCare |
Lisa Lynn |
222-22-2222 |
Joe's Grill |
PacifiCare |
PacifiCare PPO |
Independent |
*Additional info can be found in the Patient Tracking section of your
PREFERRED Users Manual... if you need a new copy, call us at 800.664.5240 or
email a request to .
Although there are no “absolute” processes, finding a way to track
PPO/network affiliation(s) in your system is a step in the right direction for accuracy
in payment and contract analysis.
Part 2 of THE MISSING LINK will be in the February Newsletter.
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