Networks, PPO's, and other ??

  1. Hi all,

    First let me say I am really happy to see this forum growing and getting more traffic. It is so good to know you can come here for support, and not have a question ignored for 6 months due to low traffic.

    Anyway, I am wondering, how many of you are working with frustrating PPO's?

    It seems like q time I try to set up home care supplies, there is a problem that req's 15 phone calls to get it right. I follow protocol, fill out the Rite Aid paperwork, which is supposed to be a one-form fax-in deal, and it has been a 2 month nightmare!

    We use a MCI deal on our home phone lines so we can make long distance calls. Here I am making oodles of calls, and my own number is appreantly showing up on the caller ID's, b/c claimants are calling me at home! It has me rather PO'd. Esp when it is 8pm on Friday night, to tell me they never got the wound care supplies I called six times about. Grrrr!!!!

    It seems like everything is so fragmented. I have to notify 12 people each time I scratch my arse! LOL!

    Well, I let my emotions the better of me, and fired off an e-mail to the boss saying if I had to go out of network to expedite things and get RELIABLE service, I would. It is so frustrating!!!!

    I am SICK of being a baby-sitter for lazy PPO agencies. Nor do I have time for that crap when I am on the road all day.

    Thanks, just needed to vent.

    Oh yeah, Can anyone explain what a "third-party payor/administrator" is? I have read it about 16 times, and still don't get it. Please put it into babytalk for me? Thanks!!!
  2. Visit hoolahan profile page

    About hoolahan

    Joined: Dec '99; Posts: 3,786; Likes: 129
    Quality Nurse & Home Health Nurse


  3. by   sunnygirl272
    Ummm...this is unrelated to your questions..but i would advise you to activate the block on your phone so that your # does not show up on CallerID...
  4. by   hoolahan
    I wasn't sure if I could do that with having to dial the 10-10-220 thingy too. I'll try it. I assumed, that it would come up on their caller ID as MCI customer, or something like that. WRONG!!
  5. by   renerian
    Hoolahan I have run into that as a home health RN working with case managers!!!!LOL. They tell me to update them on day so and so. I call leave an update or fax a written update and GOD knows where it goes but not to the person I sent it to. The bills get denied and I have to show fax cover sheets with validated times to get bills paid. I have also run into bills for supplies not being paid for and then they won't release supplies so families have to pay for them out of pocket.......

    Sorry I guess this was kinda off the topic......................

    Big smile,

  6. by   LasVegasRN
    I work for a PPO currently, and have worked for TPA and insurance company. Also have done independent case management. Okay, I've done some of everything except work as a showgirl.

    With the PPO I work with, we have several different insurance companies that access our network and some that also use our utilization management services. When I get a call, the first thing I have to ask is what insurance the patient has. I need to know this because not everyone requires prior authorization for the same thing. For instance: one insurance company does not require prior auth for outpatient diagnostic tests. Another requires authorization for any tests over $300. Another requires prior auth for only CT's, MRI's, EMG/NCS's. We have ONE form for all the providers to fill out that tells us what we need to know in order to process the request. Right now we have everything done the same day.

    Most PPO's should have a directory of their participating providers. Most should now have access to their providers on a website.

    TPA - Third Party Administrators: Say you own a large doughnut shop. You want to stay very hands on with the management of your doughnut shop and don't want to have to get bogged down in trying to see if the medical care you have for your workers is getting out of control or not. You want to save as much as you can by not having to pay their medical costs out of your own pocket. You hire a TPA to review your employee's medical claims for medical necessity, and pay the claims out of a fund you have set up through the TPA. The TPA may further help you by saying, "look, we can also help you with your workers compensation costs in the same way, let us help you (for a few extra bucks) and we'll throw in some case management to help contain your costs". So while you are trying to contact the doughnut shop for the needs of the worker, they may refer you to their TPA because they have hired the TPA to handle those things for them.

    Hope that helps!
  7. by   ryaninmtv
    The PPOs we use are actually quite friendly. A lot of that has to do with the size of the MCO I work for and the percentage of the market they cover. With workers' comp, at least here in Ohio, the law and governing authorities with mandate that the injured worker must be made whole. As such, we try to get the PPO to join in but if we can't, we pretty much tell them to pound sand.

    TPA's here are more concerned with claims management, as opposed to medical management. I work with a number of TPAs and we are very up front that the legal and claims piece is their's. We just want to deal with the medical. Most let us do our job as they aren't nurses and don't want to touch medical issues with a ten-foot pole.

    My $0.04, adjusted for inflation.