Providers have a difficult enough time practicing medicine and delivering healthcare services.  To generate adequate patient volume and to remain competitive, most providers must enter into contractual PPO arrangements with multiple payers.  Moreover, these payers usually market and administer numerous products with varying payment protocols and schedules.  As such, provider office managers, bookkeepers, and accountants are often confused about which discounts are justified and which are not.  Provider discount abuse is intended to capitalize on this confusion.

Providers often cannot resolve either silent PPOs or PPO network stacking problems because the activity of applying unjustified discounts takes place behind the scenes without arousing the provider’s suspicions.  Moreover, in most cases of silent PPO and PPO network stacking, the provider is unwittingly led to believe that the discount is a legitimate contractual discount (by employing false and misleading information on the EOB regarding the nature of the discount taken).

To exacerbate the problem, once such a practice is identified, it may be difficult and time consuming to resolve.  In part, this is because the definition of “payer” in a typical PPO contract is designed to create confusion by ostensibly allowing the party responsible for payment to be practically anyone.  By example, many contracts define the payer as an employer, insurer, HMO, PPO, TPA, labor union, trade organization, or other person or entity.  And some contracts do not require all of the payer entities to abide by the provisions of the provider’s contract with the subject plan.