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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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Dr. Robert Joseph, a podiatrist in California, who was indicted by the United States District Court for the Central District of California for the illegal practice of colluding with pharmaceutical marketers for writing prescriptions of compounding drugs, is now working undercover for the FBI. In exchange for a lower sentence due to his indictment in 2018, Dr. Robert Joseph is now working undercover to deceive medical facilities and doctors by intentionally offering illegal deals.

This article is to help warn medical facilities and doctors of the devious practice that the FBI is taking to catch them in the act. It is one thing to investigate incidences due to patient complaints or whistleblowers but to intentionally embed a mole to create a problem when there is no problem, this is how the FBI works. If Adam is tempted by the apple because it was offered is that the same as if he had already bit the apple without the temptation created by Eve? In this case, the FBI is going fishing in hopes of finding something.

A medical facility in Huntington Beach, CA was a victim of Dr. Robert Joseph and the FBI. Dr. Joseph came into the facility wearing a concealed camera and had the intention of catching them by offering an illegal deal. Fortunately, this medical facility did not take the bait but wanted to share their experience with the public so that other medical offices and doctors will be aware of Dr. Robert Joseph.

As the public, we want doctors to care about us and to do what’s best for us and not be greedy. That is the oath they take when they become doctors. There are doctors who are tempted to sway but being tempted versus actually acting on greed is not the same. What the FBI is doing is turning the tempted into greedy criminals. 


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 Các phương pháp điều trị da bất hợp pháp đang được cung cấp trong các nơi chăm sóc da mặt và tiệm cắt tóc như được phát hiện bởi các cuộc điều tra bí mật gần đây về các nơi chăm sóc da mặt và tiệm cắt tóc ở Nam California. Đàn ông và phụ nữ đang trả 150 đô la cho mỗi lần khám cho các phương pháp điều trị bằng tế bào gốc, vi kim và collagen của các chuyên gia thẩm mỹ không được cấp phép hành nghề y tế. Tất cả những nơi chăm sóc da mặt và tiệm cắt tóc nói rằng họ có y tá và bác sĩ trong đội ngũ nhân viên nhưng các quy trình thực sự được thực hiện bởi các chuyên gia thẩm mỹ không có bằng hành nghề y này. Họ quảng cáo cung cấp tế bào gốc, collagen, vi kim để tiêm Vitamin C, PRP (Platelet-Rich Plasma) injections và phương pháp điều trị bằng laser IPL cũng như các quy trình làm đầy, botox, dùng kim để nặn mụn và mài da siêu nhỏ. Tất cả các quy trình này đều đi dưới bề mặt da và xâm lấn, vì vậy chúng cần có giấy phép hành nghề y tế và phải được y tá hoặc bác sĩ thực hiện. Hội đồng Nghề Làm tóc & Thẩm mỹ Tiểu bang không cho phép các chuyên viên thẩm mỹ và chuyên gia thẩm mỹ tham gia vào bất kỳ thủ thuật xâm lấn nào. Chúng chỉ được phép hoạt động trên bề mặt da. 

Khách hàng thường nhầm lẫn các dịch vụ thẩm mỹ xâm lấn này với các dịch vụ hoặc sản phẩm chăm sóc da mặt và biểu bì. Ví dụ, một loại kem dưỡng da có thể quảng cáo rằng nó làm mịn và đẹp da của bạn (dùng trong mỹ phẩm), tuy nhiên, nếu nó quảng cáo rằng nó sẽ chữa khỏi hoặc điều trị mụn trứng cá, thì đó có thể được coi là hành nghề y. Một chiếc máy có thể quảng cáo rằng nó hỗ trợ thẩm thấu các chất dưỡng ẩm, dưỡng ẩm để làm đẹp làn da của bạn (dùng trong mỹ phẩm), tuy nhiên, nếu nó tuyên bố sẽ giảm cellulite hoặc kiểm soát cơn đau, thì đây được coi là một phương pháp hành nghề y. Một chất lột da có thể quảng cáo rằng việc sử dụng nó sẽ loại bỏ các tế bào da chết không mong muốn và thúc đẩy làn da sáng, đầy sức sống (dùng trong mỹ phẩm), tuy nhiên, nếu chất lột da tuyên bố loại bỏ các đốm nâu hoặc sẹo, thì đó có thể được coi là hành nghề y học. Người tiêu dùng cũng nên biết ai đang thực hiện các thủ tục này. Ngay cả khi họ có treo giấy phép của y tá hoặc bác sĩ tại doanh nghiệp, hãy yêu cầu cá nhân thực hiện dịch vụ trình ra giấy phép hành nghề y của họ và đảm bảo rằng đó là giấy phép được cấp bởi Bộ y tế chứ không chỉ là Giấy phép của Hội đồng Nghề làm tóc & Thẩm mỹ của Tiểu bang. 

Với $150, khách hàng đang tự đặt mình vào rủi ro và các quy trình hoặc sản phẩm này sẽ gây ra tổn thương vĩnh viễn nếu không được thực hiện bởi những người hành nghề y được cấp phép bởi Bộ y tế. Nếu người tiêu dùng phát hiện ra rằng một hành vi bất hợp pháp đang diễn ra, hãy báo cáo các hoạt động này cho Hội đồng Nghề Làm tóc & Thẩm mỹ Tiểu bang tại


 Illegal skin treatments are being offered in beauty salons as discovered by recent undercover investigations of salons in Southern California. Men and women are paying $150 per visit for stem cells,  micro-needling, and collagen treatments by estheticians and cosmetologists that are not medically licensed. These salons say they have nurses and physicians on staff but the procedures are actually done by estheticians and cosmetologists. They advertise offering stem cells, collagen,  micro-needling to inject Vitamin C, PRP (Platelet-Rich Plasma) injections, and IPL laser treatments as well as fillers, botox,  extractions, and microdermabrasion procedures. All of these procedures go below the surface of the skin and are invasive, so they require a medical license and must be administered by a nurse or physician.  The State Board of Barbering & Cosmetology does not allow cosmetologists and estheticians to engage in any invasive procedures. They are only allowed to work on the surface of the skin. 

Customers often mistake these invasive cosmetic services for facials and epidermal services or products. For example, a skin cream can advertise that it smooths and beautifies your skin (cosmetic use), however, if it advertises that it will cure or treat acne, it could be considered the practice of medicine. A machine could advertise that it assists in the penetration of hydrating moisturizers for the beautification of your skin (cosmetic use), however, if it claims to reduce cellulite or manage pain, this is considered a practice of medicine. A skin peeling agent could advertise that its use will remove unwanted dead skin cells and promote vibrant, glowing skin (cosmetic use), however, if the skin peeling agent claims to remove brown spots or scarring, it could be considered the practice of medicine. Consumers should be aware of who is performing these procedures as well. Even if they have a nurse or doctor’s license posted at the business, ask the individual performing the service for their license and make sure that it is a medical license and not just a State Board of Barbering & Cosmetology License. 

For $150, customers are putting themselves at risk and these procedures or products cause permanent damage if not done correctly by some with a medical license. If a consumer discovers that an illegal practice is taking place, report these activities to the State Board of Barbering & Cosmetology at 


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Health Insurance Use Wordplay to Deceive Providers and Patients




Huntington Beach, Calif., February 26, 2023 – Insurance verification is a critical step in the healthcare industry that ensures healthcare providers receive payment for services rendered to patients. The process involves verifying a patient’s insurance coverage and benefits with their insurance provider.

The initial step is to confirm that the patient’s insurance information is correct. Once the insurance information is confirmed, the healthcare provider checks the patient’s eligibility for the services they are seeking. This includes checking the patient’s policy coverage, deductible, co-pay, and co-insurance. If the healthcare provider is out-of-network, the provider and facility obtain authorization from the insurance carrier for approval and are provided with the usual, customary, and reasonable (UCR) or RC (Reasonable and Customary) rate. Based on the UCR or RC rate provided by the insurance, the out-of-network provider, facility and patient understand how much the insurance company will reimburse if they are to proceed.

This is when insurance companies use wordplay to deceive out-of-network providers and patients. They develop terminology to define what their reimbursement rate will be by replacing standard terms like UCR and RC with “MNRP (Maximum Non-Network Reimbursement Plan)” and “California Fee Schedule Rates” or “Official Medical Fee Schedule (OMFS)” to confuse patients and providers. Most patients, let alone medical providers, will not understand what this means unless they read the fine print. This information is also not shared when providers obtain authorization over the phone from insurance companies. Their reasoning is, “don’t ask, don’t tell.”

So to be clear about what the reimbursement of an out-of-network procedure will be, out-of-network providers must ask the following questions:

1)     Will you pay according to the UCR / RC rate?

2)     What percentage will the Provider get paid?

3)     Will the plan pay according to benefits to the out-of-network provider?

4)     What is the patient’s copay and deductible?

5)     Will you be paying based on the Medicare rate?

6)     What is your reimbursement rate based on; UCR, RC, Medicare, MNRP, California Fee Schedule, or OMFS rate?

7)     What is the percentage of the “UCR, RC, Medicare, MNRP, California Fee Schedule, or OMFS” rate you are paying?

Most providers ask questions 1-4 but if providers do not ask the follow-up questions 5-7, they will realize that they were deceived. 

So what does MNRP, California Fee Schedule Rate, or OMFS mean? It means that if the provider is out-of-network, the insurance company is reimbursing them based on a percentage of Medicare rate and not the UCR or RC. 

How will that affect the patient? If a patient purchases a PPO plan so that they can go to any nationwide provider or specialist and goes to an out-of-network provider, the insurance company will only pay MNRP (Maximum Non-Network Reimbursement Plan), California Fee Schedule Rates, or Official Medical Fee Schedule (OMFS), basically Medicare Rate. Insurance companies do not disclose this to patients and don’t want to disclose it to out-of-network providers, fearing the provider will decline the service. If this is the case, the out-of-network provider will not want to perform the procedure.

On the other hand, if the out-of-network provider proceeds with the procedure based on good faith and only receives reimbursement comparable to Medicare rate, the patient has to absorb the remaining balance. Either way, the patient is screwed and was cheated by the insurance company. The patient was deceived by the insurance company when they purchased the PPO plan believing that they will be covered when they see a specialist for their treatment, but in the end, they are left with more out-of-pocket costs than they had expected.

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