Health

MULTIPLAN: COMPANY’S INFORMATION SHARING, MEETINGS, PRACTICES COULD RAISE ANTITRUST CONCERNS, EXPERTS SAY

Published

3 years ago

August 23, 2022

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Published on Mar 07, 2022 – The Capitol Forum

Multiplan (MPLN), a company that helps health insurers underpay healthcare provider bills, may have an antitrust issue on its hands, according to experts who reviewed Multiplan practices that came to light during testimony in a recent litigation between a health insurer and emergency medicine staffing company TeamHealth.

The antitrust concerns relate to court testimony showing that Multiplan shared information with UnitedHealth Group (UNH) about competing insurers’ rate caps and hosted annual meetings where executives of competing health insurance companies gathered to discuss their successes with using Multiplan.

When asked for comment, Multiplan did not specifically answer questions related to antitrust risk and simply stated that the company “stands by all of our services, including our Data iSight and Viant pricing methodologies.”

Evidence of Anticompetitive Information Sharing

In 2016, when UnitedHealth was in talks with Multiplan about how to best implement Multiplan’s repricing services, Multiplan told UnitedHealth that seven of its top 10 competitors were using Data iSight, a Multiplan pricing database.

“Implementing these initiatives will go a long way to bringing UnitedHealth back into alignment with its primary competitor group [Blues, Cigna, Aetna] on managing out-of-network costs,” Multiplan sales executive Dale White wrote in a 2016 email to now retired United vice president of out-of-network programs John Haben, according to trial testimony. White was recently appointed CEO of Multiplan.

The case was filed against UnitedHealth Group, the parent of UnitedHealthcare, the nation’s largest health insurer, by Nevada subsidiaries of TeamHealth, an emergency medicine staffing company who claimed UnitedHealth had been underpaying them for years. A jury in November sided with TeamHealth, awarding the company more than $60 million in punitive damages. Multiplan was not a party to the case; however, testimony about the company’s practices and documents was prominently featured.

A key factor in UnitedHealth’s decision to move forward with Multiplan’s claim repricing tools was hearing from Multiplan that its Data iSight tool “was widely used by our competitors,” UnitedHealth vice president of out of network payment strategy Rebecca Paradise testified during trial.

Another UnitedHealth executive, Scott Ziemer, testified, “This is a space that we were behind some of our largest competitors.”

Multiplan, according to Ziemer, recommended UnitedHealth would be more competitive if it approved a specific price override be programmed into Data iSight so that the prices the database spit out would never exceed a predetermined amount. “The recommendation at that point from Multiplan was to go to 350% [of Medicare’s rates],” testified Ziemer about Multiplan’s specific pricing recommendation.

John Haben, the retired UnitedHealth executive, testified that it was not unusual for White and Multiplan to provide feedback about what others in the market were doing. By reducing United’s out-of-network payment threshold to 350% of Medicare, UnitedHealth knew it would “be in line with another competitor…leading the pack along with another competitor,” according to Haben’s testimony about a 2017 email and presentation he sent to coworkers titled “[Outlier Cost Management]-Multiplan Benchmark Pricing Overview.”

“Today, our major competitors have some sort of outlier cost management; they use Data iSight. United will be implementing July 1, 2017,” the attorney for UnitedHealth read from the email and presentation on the ninth day of the trial. “We want to get together with Dale [White] from Multiplan this morning…to discuss potential opportunity to improve outlier cost management by $900 million,” according to the discussion about the email during Haben’s testimony. Haben’s documents detailed several Multiplan services that UnitedHealth would be utilizing to ensure payment would not exceed 350% of Medicare rates.

UnitedHealth chose to start with a less aggressive approach when it onboarded with Data iSight, one that would put United in the “middle of the pack of its peers,” but over time lowered the override to further reduce provider payments, according to Haben’s testimony.

Multiplan vice president of health care economics Sean Crandell testified during the UnitedHealth trial that “all of the top 10 insurers in the U.S.” are among Multiplan’s clients.

Testimony during the trial also revealed that Multiplan hosted annual Client Advisory Board meetings where executives of competing health insurance companies gathered to discuss their successes with using Multiplan.

Antitrust Experts Analyze Information Sharing Evidence

Antitrust concerns often emerge when companies work together, or through a middleman, to illegally drive prices up or down, according to antitrust law experts who spoke to The Capitol Forum.

To be sure, there is a legitimate scope for competing firms to exchange information that will help them be more effective competitors and better informed about the market, Doug Melamed, an antitrust law professor at Stanford University, told The Capitol Forum. But antitrust issues arise, he said, when those communications cross the line from a reasonable exchange among competitors to communication that looks designed help them behave in a very uniform way on the specifics of their terms of trade.

Cleveland State University antitrust law professor Christopher Sagers told The Capitol Forum that if Multiplan collected competitively sensitive information from some insurers and shared it with others, the company could face antitrust liability in two different ways.

First, if the information sharing caused a reduction in insurers’ pay-outs to providers, the information sharing in and of itself could be illegal. And second, the information sharing could be evidence of a price-fixing conspiracy among the insurers to which Multiplan was a party—an arrangement that would be per se illegal.

A hub-and-spoke conspiracy problem arises, said Melamed, when the hub provides assurances to one firm that an aggressive pricing strategy is being adopted by one or more competitors of that firm to “provide mutual comfort that the aggressive pricing would not be a competitive disadvantage.”

“Smoking gun evidence of a hub and spoke conspiracy would show hub going back and forth between horizontal defendants saying, ‘You should change your price because your competitor is charging XYZ,’” Sagers said.

“If you can establish a practice of that behavior, it would be a pretty solid case for hub-and-spoke conspiracy, especially if you can show that there’s a pattern of behavior like that amongst all the defendants and the prices stabilized over time, or the prices on average significantly went down over time. Then you’ve got a really solid case,” he said.

“You are not supposed to be able to do that in competitive markets,” said Sagers.

Courts have said information sharing among competitors that has the effect of lowering prices is illegal, even if the lowered prices are not identical, especially if the industry is a highly concentrated one with significant barriers to entry and prone to follow-the-leader, or “oligopoly,” behavior, Sagers explained. These cases “often involved some trade association or coordinator that collects all the information and then distributes it to all members with forward-looking predictions or advice about what prices to charge,” added Sagers.

Capitol Forum Analysis of Information Sharing Evidence

Multiplan consults closely with health insurers on how to set prices, and careful antitrust mitigation policies would likely involve firewalls and compliance policies to ensure that information obtained from one insurer did not play a role in consulting on price with another.

Multiplan’s conduct could be problematic because the company actually markets its services, and the customers’ experience using them, as a way to match competitors on setting prices and, ultimately, reducing costs. In this sense, a typical sales pitch like “all your competitors are doing it,” could become much more problematic because the service itself is a price setting tool that retains an awareness of rivals’ pricing.

When Multiplan engages in consulting services on setting the price, the trial testimony indicates that it lets customers know where they are compared to their competitors. Haben in his testimony said that UnitedHealth was using Data iSight initially to be in the “middle of the pack of its peers,” but over time lowered the override to further reduce provider payments. That could show an ongoing knowledge of competitor behavior and an ability for Multiplan and its insurer customers to set prices relative to peers on an ongoing basis.

Evidence About Multiplan Hosting Health Insurance Executives at Company Meetings

Since at least 2015, Multiplan senior sales executives have hosted Client Advisory Board (CAB) meetings attended by executives of competing insurance companies. Multiplan invited active and prospective clients to CAB meetings held at luxury spa resorts such as the Montage Laguna Beach, according to sources who spoke with The Capitol Forum.

The attendee list for the 2019 CAB meeting included executives from UnitedHealth, Aetna Inc (AET), Cigna Corp (CI), Humana Inc (HUM), and several other insurers, according to trial testimony of two UnitedHealth executives.

Paradise, the UnitedHealth vice president of out of network payment strategy, testified about the CAB meetings saying, “Typically they talk about things they’ve implemented, other things they’re looking at, providing other industry new information.”

She described a slide that was part of a Multiplan PowerPoint presentation White gave at the 2019 meeting. According to a discussion between Paradise and an attorney representing UnitedHealth, the slide showcased years’ worth of medical costs and the medical cost reduction Multiplan achieved for insurers. Multiplan’s services, The Capitol Forum found, include allowing insurers to set their own “meet or beat” prices and slashing certain treatment codes off of medical claims before pricing the claim, a process Multiplan refers to as payment integrity edits to claim in SEC filings.

To promote Data iSight at CAB meetings, Multiplan sat prospective clients together with active clients as a sales strategy, according to a 2017 Multiplan document reviewed by The Capitol Forum that discussed a CAB meeting that had taken place two years prior.

Source: Redacted excerpt of a 2017 Multiplan document

Blue Cross Blue Shield Association declined to comment citing active litigation, referring to the Verity case.

Health insurers UnitedHealth, Aetna, Cigna, Anthem (ANTM), Centene subsidiary Wellcare (CNC), and Humana did not respond to a request for comment for this story.

Antitrust Expert Analyzes Hosted Meetings Evidence

“If what they are talking about at these meetings is a very specific current terms of trade,” said Melamed, like “’Here’s how we can get providers to take our prices,’ or ‘Here’s what we are going to pay for certain kinds of services,’ then that gets out of the area of generally making the various firms more knowledgeable and sophisticated about the market and gets into the area of enabling them to agree on specific terms of trade.”

Capitol Forum Analysis of Evidence Related to CAB Meetings

The goal of Multiplan’s client advisory board meetings was specifically to have clients discuss their experiences with a product that allows them to remove billing codes and set prices. That involves consulting with Multiplan in an ongoing way about competitors’ pricing. If Multiplan and its customers discussed specifics about how they were using Data iSight to set prices—ostensibly the biggest benefit of the service—it would likely be problematic from an antitrust perspective.

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Business

WHY HEALTH INSURANCE COMPANIES AVOID PAYING CLAIMS

Published

4 months ago

June 1, 2025

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Health insurance is supposed to be a safety net—a financial buffer to help cover medical costs when life throws a curveball. But if you ask any provider or patient who’s tried to collect on a claim, they’ll tell you, “Insurance companies don’t play fair.” In fact, many go out of their way to avoid paying out, delay the process, or set up confusing roadblocks that frustrate both doctors and patients.

Insurance companies make it so hard to get paid because profit is their priority. At the end of the day, health insurance companies are businesses. And like all businesses, they have one main objective: maximize profits. Every claim they pay out cuts into their bottom line. That creates a built-in incentive to delay, deny, or underpay whenever possible.

Even small denials, when multiplied by thousands of claims a day, can result in massive savings for insurers. Insurance policies are loaded with fine print, technical jargon, and changing criteria. Providers are often expected to navigate complex billing codes, formularies, pre-authorization procedures, and specific documentation requirements—all of which can change without much notice. This constant state of fluctuation increases the chances of providers making an error, giving insurers the excuse they need to deny or delay a claim.

Pre-authorization is one of the most common tactics used to stall or prevent payments. It requires providers to get approval in advance for many tests, treatments, or medications—even those considered standard of care. The process can be so drawn-out and inconsistent that some providers give up or delay care, leaving patients in limbo.

Insurers frequently deny claims based on minor technical errors, such as misspelled names, incorrect billing codes, lack of “medical necessity” (even when a doctor deems it necessary), or missing documentation (often something that was never clearly requested) In many cases, the care was valid and needed—but one small mistake is all it takes to trigger a denial.

Some experts refer to it as the “three D’s”: Delay, Deny, and Defend. Their goal is to wear people down. Insurance companies know that if they make the process frustrating enough, many patients and providers will give up on pursuing the money altogether. Time-consuming phone calls, appeals processes, and re-submissions become a full-time job. Many doctors and clinics can’t afford to keep up with.

In some cases, insurers will pay less than what was agreed upon, or use so-called “silent PPOs” to undercut contracted rates. Providers often don’t even realize they’ve been underpaid until months later, by which point the appeals window may have closed. This subtle tactic lets insurers save money without outright denying care—flying under the radar of most busy practices.

In recent years, insurers have begun using algorithms and artificial intelligence to flag and auto-deny claims at scale. While these tools are promoted as efficiency boosters, they can result in denials that lack nuance, context, or human judgment. This can be particularly harmful for complex or rare conditions, where standard guidelines may not apply. This impacts patients and providers in many ways; doctors and hospitals must hire full-time billing and coding staff just to stay afloat, patients are often left with surprise bills or denied access to necessary care, and healthcare costs rise as administrative work eats up time and resources. In short, when insurers deny payment, everyone else pays the price—whether it’s through stress, delayed care, or rising premiums.

So although health insurance is supposed to provide peace of mind, too often, it feels like a battle. Between red tape, strategic delays, and vague policies, insurers have turned claim denial into a quiet art form. Until there’s more oversight, transparency, or reform, providers and patients will need to stay vigilant—document everything, ask questions, and never take a denial at face value.

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TẠI SAO CÁC CÔNG TY BẢO HIỂM Y TẾ TRÁNH TRẢ TIỀN BỒI THƯỜNG

Bảo hiểm y tế lẽ ra phải là một tấm lưới an toàn tài chính—giúp người bệnh chi trả chi phí y tế khi gặp khó khăn. Nhưng nếu bạn hỏi bất kỳ bác sĩ hay bệnh nhân nào từng cố gắng nhận tiền bồi thường, họ sẽ nói: “Công ty bảo hiểm không chơi đẹp.” Thực tế, nhiều công ty cố tình né tránh, trì hoãn hoặc tạo ra các thủ tục rắc rối để gây khó khăn cho cả bác sĩ lẫn bệnh nhân.

Lý do chính khiến việc đòi tiền bảo hiểm trở nên khó khăn là vì lợi nhuận. Các công ty bảo hiểm y tế là doanh nghiệp, và mục tiêu chính của họ là tối đa hóa lợi nhuận. Mỗi khoản bồi thường mà họ phải chi trả làm giảm lợi nhuận, vì vậy họ có động cơ để trì hoãn, từ chối hoặc trả ít hơn bất cứ khi nào có thể.

Ngay cả những khoản từ chối nhỏ, khi nhân lên hàng ngàn đơn mỗi ngày, cũng giúp họ tiết kiệm một khoản tiền khổng lồ. Hợp đồng bảo hiểm thường chứa nhiều điều khoản khó hiểu, ngôn ngữ kỹ thuật, và quy định thay đổi liên tục. Các bác sĩ phải đối mặt với mã hóa phức tạp, danh mục thuốc, quy trình xin chấp thuận trước và yêu cầu tài liệu chi tiết—tất cả có thể thay đổi mà không báo trước. Những thay đổi liên tục này khiến bác sĩ dễ mắc lỗi, và đó là cái cớ để công ty bảo hiểm từ chối hoặc trì hoãn thanh toán.

“Xin chấp thuận trước” là một chiêu trò phổ biến nhằm trì hoãn hoặc tránh phải chi trả. Nó yêu cầu bác sĩ phải được công ty bảo hiểm chấp thuận trước khi thực hiện nhiều xét nghiệm, điều trị hoặc kê đơn—even khi đó là phương pháp điều trị tiêu chuẩn. Quá trình này có thể kéo dài, thiếu nhất quán, khiến nhiều bác sĩ bỏ cuộc hoặc trì hoãn điều trị, làm bệnh nhân phải chờ đợi không biết đến bao giờ.

Công ty bảo hiểm thường từ chối chi trả chỉ vì lỗi kỹ thuật nhỏ—như tên bị đánh sai, mã hóa sai, cho rằng “không cần thiết về mặt y khoa” (dù bác sĩ cho là cần), hoặc thiếu tài liệu (nhiều khi là tài liệu mà họ không nói rõ từ đầu). Trong nhiều trường hợp, việc điều trị là chính đáng và cần thiết—nhưng chỉ một lỗi nhỏ cũng đủ khiến họ từ chối bồi thường.

Một số chuyên gia gọi đây là chiến lược “ba chữ D”: Delay (Trì hoãn), Deny (Từ chối), và Defend (Chống chế). Mục tiêu là làm người ta mệt mỏi và bỏ cuộc. Họ biết nếu gây đủ phiền toái, nhiều bệnh nhân và bác sĩ sẽ từ bỏ việc theo đuổi quyền lợi. Gọi điện, làm đơn khiếu nại, gửi lại hồ sơ… trở thành công việc toàn thời gian, mà nhiều phòng khám không đủ nguồn lực để theo đuổi.

Thậm chí có khi, công ty bảo hiểm trả ít hơn số tiền đã thỏa thuận, hoặc sử dụng cái gọi là “PPO âm thầm” (silent PPO) để trả giá thấp hơn mức trong hợp đồng. Các bác sĩ thường không phát hiện ra mình bị trả thiếu cho đến vài tháng sau, khi thời hạn khiếu nại đã hết. Chiêu trò tinh vi này giúp công ty bảo hiểm tiết kiệm mà không cần từ chối trực tiếp—âm thầm “né” khỏi sự chú ý của các phòng khám bận rộn.

Gần đây, các công ty bảo hiểm còn dùng thuật toán và trí tuệ nhân tạo để tự động từ chối hàng loạt hồ sơ. Dù họ nói rằng công nghệ giúp xử lý nhanh hơn, thực tế lại làm tăng số lượng hồ sơ bị từ chối mà không có sự đánh giá kỹ lưỡng hay cân nhắc hoàn cảnh cụ thể. Điều này đặc biệt nguy hiểm với những ca bệnh hiếm gặp hoặc phức tạp, khi không thể áp dụng quy chuẩn thông thường.

Hệ quả là: bác sĩ và bệnh viện phải thuê thêm người để làm công việc mã hóa và đòi tiền; bệnh nhân nhận được hóa đơn bất ngờ hoặc bị từ chối điều trị cần thiết; chi phí y tế tăng vì quá nhiều thời gian và nguồn lực bị tiêu tốn cho thủ tục hành chính.

Tóm lại, khi công ty bảo hiểm từ chối chi trả, mọi người đều phải trả giá—dù là bằng căng thẳng, điều trị chậm trễ, hay phí bảo hiểm tăng cao.

Mặc dù bảo hiểm y tế được kỳ vọng sẽ mang lại sự yên tâm, nhưng trong thực tế, nó lại giống như một cuộc chiến. Giữa hàng loạt thủ tục, sự trì hoãn có chủ đích, và các điều khoản mơ hồ, các công ty bảo hiểm đã biến việc từ chối bồi thường thành một “nghệ thuật thầm lặng”. Cho đến khi có nhiều minh bạch, kiểm soát và cải cách hơn, cả bác sĩ và bệnh nhân đều cần cảnh giác—ghi chép cẩn thận, đặt câu hỏi, và đừng bao giờ chấp nhận việc bị từ chối mà không phản hồi.

Business

A CRIMINAL BECOMES A MOLE FOR THE FBI

Published

5 months ago

May 5, 2025

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Dr. Robert John Joseph II, D.P.M

In July 2022, Dr. Robert John Joseph II, D.P.M., a podiatrist, pleaded guilty to misconduct and malpractice charges. He was convicted of a felony for defrauding government healthcare plans by writing compound drug prescriptions to patients and directing them to accomplice pharmacies in exchange for kickback payments.

The Department of Consumer Affairs investigation into Dr. Joseph’s practices involved detailed examination of medical records, expert testimony, and an assessment of Dr. Joseph’s actions. The core of the allegations included issues such as failure to diagnose, improper treatment methods, and negligence in patient care. The findings of the investigation led to his disciplinary action but in a plea deal, Dr. Joseph agreed to cooperate with federal authorities. As part of this agreement, he has been working undercover for the FBI to expose illicit practices by other doctors and medical facilities. His role has involved attempting to lure other doctors and medical facilities into illegal agreements.

Dr. Joseph is currently working undercover in California and has been visiting medical facilities and doctors’ offices to solicit illegal practices to see if any of them would take the bait. A medical facility in Orange County, CA, reported that Dr. Joseph, equipped with a concealed camera, attempted to offer an illegal deal as part of his undercover work. The facility did not take the bait and chose to publicize the incident to alert others about such undercover operations.

This situation underscores the FBI’s method of combating fraudulent activities, which sometimes involves setting traps to uncover wrongdoing. While the goal is to identify genuine malpractice, this approach raises ethical concerns about creating scenarios that may not have existed otherwise. It highlights the need for vigilance within the medical community to avoid being caught in such undercover operations. Essentially, this tactic risks turning tempted individuals into criminals by creating opportunities for misconduct.

https://www2.mbc.ca.gov/pdl/document.aspx?path=%5cDIDOCS%5c20231208%5cDMRAAAJD1%5c&did=AAAJD231208220712717.DID&licenseType=E&licenseNumber=4013%20#page=1

https://www.justice.gov/file/1076086/download

Health

CAN HEALTH INSURANCE COVER A NOSE JOB (RHINOPLASTY)?

Published

5 months ago

May 5, 2025

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Rhinoplasty, commonly known as a nose job, is a popular cosmetic procedure that alters the shape or structure of the nose. Many people seek rhinoplasty for aesthetic reasons, desiring a more symmetrical or balanced appearance. However, there are cases where rhinoplasty is performed for medical reasons, such as to improve breathing or correct a structural abnormality. In these instances, health insurance may provide coverage for the procedure.

The key factor in determining whether health insurance will cover rhinoplasty is the purpose of the surgery. Health insurance generally does not cover purely cosmetic procedures, meaning those that are done solely for appearance. However, rhinoplasty that is considered medically necessary—such as for functional or reconstructive reasons—may be covered.

Rhinoplasty may be deemed medically necessary in several situations, including:

Septoplasty: A common reason for insurance coverage, septoplasty involves the correction of a deviated septum, which can cause difficulty breathing. A deviated septum is a condition where the cartilage and bone dividing the nasal passages are off-center, leading to obstruction and difficulty with airflow.

Chronic Sinus Issues: If a person has chronic sinusitis or recurring infections due to nasal passage obstruction caused by a structural issue with the nose, rhinoplasty to correct the obstruction might be covered by insurance.

Nasal Fractures or Trauma: If the nose has been broken or damaged in an accident or injury, reconstructive rhinoplasty may be necessary to restore both function (breathing) and appearance. This type of surgery is often covered by insurance, especially if there is ongoing functional impairment.

Breathing Difficulties: If a person is experiencing breathing difficulties due to structural abnormalities, such as a collapsed nasal valve or congenital deformities, insurance may cover surgery to improve nasal airflow.

If rhinoplasty is performed purely for cosmetic reasons, it is generally considered elective surgery and is not covered by health insurance. However, there are cases when a patient who has sustained an injury or has a congenital defect that affects the function of the nose, in addition to its appearance, may be able to make a case for insurance coverage if they can demonstrate that the procedure will improve both function and form.

If you believe your rhinoplasty is medically necessary, the first step is to check with your health insurance provider. It’s essential to also consult with an experienced ENT (ear, nose, and throat) specialist or a board-certified plastic surgeon who can evaluate your condition and provide the necessary documentation for insurance approval.

Document Symptoms and Issues: Keep a detailed record of your symptoms, such as difficulty breathing, frequent sinus infections, or any other related issues that may support your case for medical necessity.

Appeal Denied Claims: If your insurance company initially denies coverage for rhinoplasty, don’t be discouraged. Many patients successfully appeal denied claims by submitting additional medical documentation or a letter from their doctor outlining the functional necessity of the procedure.

While rhinoplasty for purely cosmetic reasons is not typically covered by health insurance, it may be possible to get coverage if the surgery is deemed medically necessary. Suppose you’re considering rhinoplasty for functional reasons, such as to improve breathing or correct a medical issue. In that case, it’s important to consult with your insurance provider and a skilled surgeon to understand your options. Always thoroughly review the details of your insurance policy and any associated costs before proceeding with surgery.

To speak to a specialist or for more information, call Coast Surgery Center toll-free at (855) 263-9968 or (714) 375-3600.