Do PPO’s Represent You or their Providers?


This letter was sent to one of our clients from the PPO that they were accessing for discounts to their self funded medical plan.  The story is as follows:

This client had a $550,000 claim incurred on a premature baby. The facility that provided service is a childrens specialty hospital in North Texas .  Due to the fact that this facility is a specialty hospital the PPO discount is 20% across the board on all charges and with all PPO networks.  The client’s stop loss carrier had the claim audited to review for excessive markups and inappropriate services.  The audit reduced the original bill by approximately $100,000 due to excessive markups on services beyond U&C and inappropriate charges such as speech therapy, occupational therapy and educational training (on a premature baby).  The 20% discount was then applied to the reduced amount of $450,000.

The hospital complained about the audit to the PPO network and the network sent our client the letter terminating the PPO contract if the employer did not agree to pay the claim as billed minus the 20% discount.  This letter clearly states that no U&C can be applied to any bill and no audit of any type is allowed in their agreement.

 WHO ARE THE PPO’S WORKING FOR??     Read this PPO Letter before you decide what the answer is.


Comments are closed.