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

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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.

Article Source Link: https://thecapitolforum.com/multiplan-companys-information-sharing-meetings-practices-could-raise-antitrust-concerns-experts-say/?fbclid=IwAR0LChYuJ-x95oayAXcvbI4kKEbKLuxX7MfLtEDW7aHbRJ3DcZVYOPFc_FI

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A CRIMINAL BECOMES A MOLE FOR THE FBI

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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.

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

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CAN HEALTH INSURANCE COVER A NOSE JOB (RHINOPLASTY)?

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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.

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UNDERSTANDING HEALTH INSURANCE COVERAGE FOR YOUR WEIGHT LOSS PROCEDURES

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UNDERSTANDING HEALTH INSURANCE COVERAGE FOR YOUR WEIGHT LOSS PROCEDURES

Many Americans are unaware that certain cosmetic procedures, often considered elective or purely aesthetic, can actually be covered by their insurance providers—especially when they serve a medical purpose or are part of a weight loss process. This misconception often leads to people paying out-of-pocket for surgeries that could have been partially or fully covered.

While cosmetic procedures are typically thought of as enhancing appearance or boosting self-esteem, there are specific cases in which these surgeries can provide legitimate health benefits. For individuals who have experienced accidents or physical injuries, certain cosmetic surgeries can alleviate pain, restore functionality, and improve overall well-being.

For instance, reconstructive surgeries performed after accidents, injuries, or congenital defects may be covered because they are aimed at restoring the body’s function rather than purely enhancing its appearance. These surgeries can make a significant difference in a patient’s daily life by improving mobility, reducing pain, and addressing issues caused by physical trauma.

A significant area where insurance coverage comes into play is after major weight loss, particularly for individuals who undergo gastric bypass surgery or other weight loss surgeries. As part of this weight loss journey, many individuals are left with excess skin, which not only affects their appearance but can also lead to a variety of physical health issues.

Excess skin, especially around the abdomen, arms, and thighs, can cause problems such as:

Bacterial Build-up and Yeast Infections: Moist, folded skin can create an environment where bacteria and fungi thrive, leading to infections.

Ulcers and Skin Irritation: Excess skin can rub against itself, leading to painful sores, ulcers, and general discomfort.

Back and Joint Pain: The weight of excess skin can strain the body, leading to back and joint pain, making everyday tasks difficult.

In these cases, procedures like Panniculectomy (removal of excess abdominal skin), Brachioplasty (arm lift), and sometimes Butt Lift surgeries are often necessary not only for cosmetic reasons but for medical ones. Since these procedures alleviate physical health issues, insurance providers may view them as medically necessary and offer coverage, either partially or fully.

On the other hand, there are many situations in which cosmetic surgery is considered purely elective. These surgeries focus primarily on enhancing a person’s appearance and often aim to improve self-confidence or mental health. While these procedures may be life-changing for the individual, they do not directly address medical conditions or improve a person’s overall physical health. For example, surgeries like breast augmentation, facelifts, or tummy tucks that don’t stem from a medical need are typically not covered by insurance.

However, if these cosmetic procedures are combined with a medical need—such as breast reconstruction after a mastectomy—insurance coverage may apply, as the surgery is deemed necessary to restore health or function.

It’s important to note that each insurance provider has its own set of rules and guidelines regarding which procedures are eligible for coverage. Insurers typically require certain documentation to prove that the surgery is medically necessary. This process can include:

Medical Records and History: Your doctor will need to provide documentation outlining the health problems caused by excess skin or other physical issues, along with evidence that the surgery will alleviate these problems.

Pre-certification: Before undergoing surgery, patients will often need to get pre-approval from their insurance provider. This means that the insurer will review the details of the surgery and determine if it meets the criteria for coverage.

The process of getting a procedure covered by insurance can be time-consuming and sometimes complicated. It’s crucial to work closely with both your healthcare provider and insurance company to ensure that all necessary paperwork is submitted and that the surgery will be approved.

Because every individual’s situation is unique, it’s essential to have open communication with both your surgeon and your insurance company. Each person’s medical history, weight loss journey, and health challenges are different, so what may be covered for one person may not apply to another.

Before moving forward with any cosmetic surgery, you should have a thorough discussion with your surgeon about the medical necessity of the procedure. Your doctor can provide documentation to help justify why the surgery should be considered medically necessary, as opposed to purely cosmetic.

Additionally, contacting your insurance company directly to discuss coverage options and understand any specific requirements will help avoid unexpected costs. They may also provide you with a list of necessary steps for getting the procedure approved.

Most reconstructive surgeries require pre-certification, a process that involves getting approval from your insurance company before the procedure. This is especially common for surgeries related to significant weight loss, trauma recovery, or addressing chronic medical conditions caused by physical issues like excess skin.

If you’re unsure about whether your procedure qualifies for insurance coverage, it’s important to consult with both your surgeon and insurance representative. They can provide you with details on how to navigate the process and whether you need to submit additional documents.

Navigating insurance coverage for cosmetic or reconstructive surgeries can be complex, but understanding the medical necessity of the procedure can increase your chances of receiving coverage. Procedures that address specific health issues like excess skin from weight loss, injury recovery, or physical discomfort often meet the criteria for insurance approval.

For more information on cosmetic and reconstructive procedures, as well as insurance details, you can visit the COAST Surgery Center website at www.CoastSurgicalCenter.com. To speak with a representative or learn more, you can call their helpline at (855) A-NEW-YOU or (714) 375-3600 for personalized guidance.

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