The author’s survey of several PPO aggregators indicated that not one met all or most of the criteria above.  Most do not offer access to out-of-network providers with whom they have direct contractual relationships.  Many “lease” networks to gain access to discounts for a fee of 8-10% of savings only to charge payers 20-25% of savings.  Several outright boasted of PPO network stacking.

Typically, the providers accessed via PPO aggregators are not done so with their advance knowledge or in accordance with the underlying provisions of their primary PPO contracts.  Because of this, the lack of patient steerage, and no promise of higher payer benefit reimbursement, there is no contract, as there is neither a bargain for exchange, nor a meeting of the minds.  Use of these firms requires payers to make material misrepresentations to providers with deceptive EOB codes that falsely indicated that the discount being taken is pursuant to legitimate access via their PPO contract.

Using PPO aggregators may be impractical.  Many require their logo to be on the ID card, though most primary PPOs don’t allow this.  Some require provider reimbursement at the in-network benefit level even though this may be contrary to the plan document, the assumptions upon which the stop loss is based, and the practices of many payers (see TPA Network’s survey results of 100 payers).

Moreover, paying at the in-network benefit level can actually increase plan costs.  Assume an 80/60 plan design and a 20% provider discount.  The claim cost, net of a PPO aggregator fee of 25% of savings, is 85% of the UCR fee.  Paid at 80%, the ultimate cost to the plan is 68% of the UCR fee.  Paid at the out-of-network rate, sans discount, the cost to the plan is only 60% of the UCR fee.

The legitimacy of discounts obtained through PPO aggregators is questionable.  Dealing with them creates an avoidable discount reversal/denial risk to the plan sponsor, plan participant and re-insurer.