In Part I of this series, we explored how to better track your PPO affiliations with the applicable “payors.” In Part II, we further examined the difference between a PPO and a Payor.

Now, we tackle deciphering various “lease” relationships between PPOs, which also affect your A/R.

PPOs and healthplans “lease” access to other PPO networks for a variety of reasons, primarily to broaden network coverage in areas where they are lacking, and also to obtain additional cost savings for their clients.

First, a couple of disclaimers:

• The information below is generalized. There are no absolute definitions. Terms are interchangeable.
• There are far too many network variations in the PPO industry to nail them all down. This is a very basic look at some of the relationships in the market.

WRAP NETWORK: “Fills in the gaps” for other healthplans & PPOs in areas where the primary healthplan or PPO doesn’t have provider coverage. This is usually a legitimate leased arrangement between two PPOs. You might see more than one logo on the patient’s card, and benefits are usually paid in-network at the same benefit level as if the patient were using the primary PPO network.

TIERED NETWORK: Providers are divided into categories based on cost and quality; patient’s benefits may vary based on where services are rendered or which type of service is provided.

OUT OF AREA/TRAVEL NETWORK: Provides secondary network coverage for patients when they are seeking treatment out of their primary healthplan or PPO’s service area. Benefits are usually paid in-network but may be at a slightly reduced benefit level. You might see more than one logo on the card.

OUT OF NETWORK/WRAP: Provides a secondary, wrap arrangement with other primary healthplans and PPOs to offer discounts on out of network claims. Other terms for this type of arrangement are “shared savings”, or “white space management”. This is the most prominent trend causing confusion with providers at this time. You might see more than one logo on the card. If a patient goes out of network, but the provider is contracted with the secondary network, the claim is paid at the out of network benefit level, but with the secondary network’s discount applied. See Q&A below:

• Q: I am not a United Healthcare Provider, but I am a provider for Multiplan. I treated a patient who had both UHC and Multiplan on their card. Does this mean I am in-network?
• A: Most likely, NO. UHC accesses Multiplan for OUT-OF-NETWORK cost savings. UHC is the primary network. The Multiplan logo on the card indicates that you will still be paid at the out-of-network benefit level or a reduced benefit level for this patient, but the Multiplan discount will be applied to your claim.

FINAL THOUGHTS:
ACCURATE TRACKING = ACCURATE PAYMENT. With all of the variables in today’s market, it is CRITICAL to acknowledge which PPO is identified on each EOB, and track that vital piece of data along with each patient record in your billing system.