PPO Network Issues

While silent PPOs involve the impermissible use of PPO discounts to which payers are not entitled, other PPO network issues involve refusal to honor PPO network agreements to which both the payer and provider have already agreed. Instead of paying at agreed upon levels, some payers refuse to honor the agreement and pay the claims as “out of network” at substantial reductions supposedly based on UCR determinations. This practice of refusing to honor PPO agreements results in lesser reimbursement to providers and greater financial responsibility for patients.

TGF leverages the patient’s rights and argues breach of contract to force insurers to adhere to the terms of the PPO agreements, reimburse providers at agreed upon rights, and allow patients the benefits promised under the plan or policy.

  • Insurers have long engaged in abusive practices with PPO networks resulting in significant discounts to insurers to which they were not entitled
  • Many insurers are now even more blatantly abusing PPO network agreements by refusing to honor agreed upon network rates
  • This practice by insurers results in the provider receiving less reimbursement than promised and the patient being subject to unnecessary balance billing
  • TGF works with these imprudent payers and the applicable PPO networks to require adherence to the terms of PPO agreements