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By Dr. David Edward Marcinko; MBA MEd
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Physician Beware Fraudulent Faux (“Mirror”) MCO Schemes
A silent, non-directed, ghost, blind, faux, or “mirror” PPO, HMO, or other provider model is not really a formalized managed care organization [MCO] at all. Rather, it was simply an intermediary attempt, and Ponzi-like scheme, to negotiate practitioner fees downward, by promising a higher volume of patients in exchange for the discount.
Of course, the intermediary [discount-broker] then resells the packaged contract product to any willing insurance company, HMO, PPO or other payer, thereby pocketing the difference as a nice profit. Sometime, these virtual organizations are just indemnity companies in disguise.
CLEVELAND CLINIC: https://medicalexecutivepost.com/2025/05/17/cleveland-clinic-controversial-new-health-insurance-co-payment-policy/
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NOTE: The term indemnity insurance refers to an insurance policy that compensates an insured party for certain unexpected damages or losses up to a certain limit—usually the amount of the loss itself. Insurance companies provide coverage in exchange for premiums paid by the insured parties.
These policies are commonly designed to protect professionals and business owners when they are found to be at fault for a specific event such as misjudgment or malpractice. They generally take the form of a letter o indemnity.
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As part of a silent PPO scheme, insurers try to pass off the discount as legitimate on Explanation of Benefit [EOB] forms. Physicians should not fall for this ploy, since pricing pressure will be forced even lower in the next round of “real” PPO negotiations!
Medical providers should also be on guard for silent HMOs, MCOs and any other silent insurance variation, since these virtual organizations do not exist, except as exploitable arbitrage situations for the middleman.
PRE-PAID PLANS: https://medicalexecutivepost.com/2025/04/17/health-insurance-pre-paid-plans/
COMMENTS APPRECIATED
SPEAKING: Dr. Marcinko will be speaking and lecturing, signing and opining, teaching and preaching, storming and performing at many locations throughout the USA this year! His tour of witty and serious pontifications may be scheduled on a planned or ad-hoc basis; for public or private meetings and gatherings; formally, informally, or over lunch or dinner. All medical societies, financial advisory firms or Broker-Dealers are encouraged to submit an RFP for speaking engagements: CONTACT: Ann Miller RN MHA at MarcinkoAdvisors@outlook.com -OR- http://www.MarcinkoAssociates.com
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Filed under: "Ask-an-Advisor", CMP Program, Ethics, finance, Glossary Terms, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: Cleveland Clinic, david marcinko, DPM, health, Health Insurance, HMO, indemnity insurance, INSURANCE COMPANIES, MCO, MCO schemes, MD, politics, PPO, pre-paid insurance |
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