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Published on Apr 08, 2022 – The Capitol Forum

Multiplan (MPLN) says that it provides “independent, fair, and reasonable” pricing for out-of-network healthcare services.

Previous Capitol Forum reporting showed that Multiplan’s pricing is not independent, as it can be manipulated by insurers.

According to Capitol Forum’s ongoing investigation, Multiplan’s pricing is also not “fair and reasonable,” as the pricing appears to be based on maximizing profits, and, in one case, Multiplan admitted that, when setting prices, it relied on how much Multiplan discounted from the provider’s previous billed charges. Basing pricing on the percentage discounted from a provider’s previous charges is not a process that could reasonably be described as yielding “independent, fair, and reasonable” pricing for healthcare services, but it is perfectly logical for Multiplan since the company is paid based on the percentage difference between billed rates and prices paid by insurers.

Multiplan argues that its services that bring in “shared savings” fees help employers and patients, but when Multiplan cuts the rates for healthcare claims, either the employer is hurt by an increase in fees or the patient is hurt by receiving a large “balance bill.”

For this article, we focus primarily on three medical billers’ interactions with Multiplan.

One biller showed how Multiplan punished him for lowering his billing rate and rewarded him for raising his billing rate.

Another biller showed how Multiplan pricing left patients with big increases in out-of-pocket costs for physical therapy services.

Another biller described the process of Multiplan’s pricing as difficult to manage, opaque, and dramatically lower than pricing done by non-Multiplan-affiliated plans.

Each of the billers emphasized the amount of administrative time and expense that was necessary to deal with Multiplan-facilitated claims and to educate patients about unexpected increases in their portion of the bill.

For this part of its investigation, The Capitol Forum reviewed redacted “fee negotiation” communications between Multiplan and providers, insurance claim payment remittances, and documents filed in several lawsuits, including depositions, trial transcripts, and exhibits; interviewed several providers and owners of medical billing companies who spoke under the condition of anonymity because of concerns about retaliation from Multiplan and payors; read online provider complaints posted by providers; and interviewed a former Multiplan fee negotiator.

Multiplan spokesperson’s comments. “All of our pricing methodologies are fair, transparent and reasonable. Multiplan absolutely does not encourage providers to overcharge for their services—that is completely in opposition to our mission and would not be tolerated by us or by our clients,” a Multiplan spokesperson told The Capitol Forum in an emailed statement.

The Multiplan Billing Experience vs. the Typical Health Plan Billing Experience

Whereas a typical health plan sets an allowable rate for a healthcare service, some health plans first route out-of-network claims to Multiplan’s “negotiating services.” In effect, a provider sends a bill to the insurance plan, the plan routes the claim to Multiplan who offers an “adjusted price” (or “negotiated rate”) as part of a negotiation. Providers told The Capitol Forum that the adjusted price offer is a take-it-or-leave-it proposal. If the provider accepts the adjusted price, then the provider agrees not to balance bill.

This creates an unusual circumstance when there is a large gap between the billed charge and agreed negotiated rate. When setting future adjusted prices for a provider’s claims, Multiplan appears to rely on the percentage discounted from the billed charge rather than a specific dollar amount for a given service. When a provider decides to bill a subsequent claim for the same service at Multiplan’s previously accepted adjusted price, Multiplan responds with an almost proportionately lower adjusted price offer.

Effectively, negotiated rates with Multiplan, after the first negotiation, are phantom rates because Multiplan appears to stabilize the percentage gap between what a provider bills and the adjusted price the provider accepts. The provider knows what adjusted price Multiplan offered previously, but the provider will not be offered the same adjusted price again unless the billed charges remain at an inflated amount.

If the provider rejects Multiplan’s negotiated rate, the claim is paid much lower than the typical allowable rate which results in the provider balance billing the patient for the difference between the billed price and the allowable rate.

Here are some examples of out-of-network claims sent to health insurance plans that use Multiplan pricing services and the end results of those negotiations with Multiplan.

Employers who self-fund health plans for employee health coverage pay insurance companies to administer the plan. The insurance companies charge employers fees, including fees for out-of-network claim management services and, when Multiplan is involved, the insurance company shares a portion of that fee revenue with Multiplan.

If the provider accepts Multiplan’s negotiated payments, then the employer pays high “shared savings” fees to the insurance company administering the health plan. Shared savings fees are based on a percentage of the amount between providers’ billed charges and the negotiated amount shown on the claim statement. Previously, The Capitol Forum reported on employers’ dissatisfaction with the shared savings fees.

Case Study 1: Biller for Surgery Centers

A biller who works in a western state with surgeons and surgery centers for specialties including neurosurgery, bariatrics, and gynecology, told The Capitol Forum in an interview, “The typical allowable rate received by our facility for complex upper endoscopy procedures performed prior to bariatric surgery was between $6,000 and $8,000. However, Multiplan and Anthem (ANTH) refused to honor that price unless we billed three to four times higher” than the negotiated rate.” So, the biller said he typical billed between $18,000 to $28,000—and sometimes as high as $32,000—to get paid between $6,000 to $8,000 from the Multiplan-affiliated health plans.

Then, in May 2020, the biller said Multiplan suddenly reduced its negotiated price to $3,539. The biller billed $32,000 to get the $3,539 adjusted price from Multiplan. He agreed to accept that rate as full payment and promised not to balance bill, as is required when providers accept a negotiated rate offered by Multiplan.

In June 2021, the biller dropped his price to $24,000, and Multiplan dropped its negotiated rate to $3,096, which the biller accepted.

Finally, in November 2021, the biller dropped his billed rate to $4,500 because he no longer wanted to choose between writing off larger amounts and balance billing patients. The biller anticipated that Multiplan’s negotiated rate of $3,096 or $3,539 would leave a more manageable $1,000 or $1,500 to write off or to balance bill to the patient.

But, instead of offering close to the previous adjusted prices of $3,096 or $3,539, Multiplan responded to the provider’s price cut by slashing the negotiated rate down to $673.65.

Source: Redacted Multiplan negotiated offer

In voicemails left by a Multiplan negotiator, the biller said he was told, “the claim is set at the same rate, as far as percentage goes. I am not able to increase it due to the maximum allowed amount.” According to the biller, the Multiplan negotiator in a follow up call “confirmed that the previous rate of $3,500 will not be offered until I increase the billed total.”

The biller persisted in asking questions about the formula Multiplan used to justify a decrease in the offered rate from $3,500 to $673.65 for the same procedure. He said the negotiator explained, “The allowable amount percentage is based on the percentage you had accepted in previous Anthem claims for similar plan and similar procedures.”

In reality, the new Multiplan payment was roughly 15% of the billed amount, whereas the previous offers were roughly 13% and 11% of billed charges, so it is unclear what the Multiplan representative meant by saying “the rate was the same, as a percentage.” But the explanation does indicate that, rather than independently assessing a “fair” price, Multiplan adjusts negotiated rates to maintain the percentage gap between billed charges and the offered price.

In a subsequent claim, the biller raised the charge to $28,000, and Multiplan increased the amount it offered to $2,548, thereby rewarding him for raising the price more than sixfold.

Anthem did not respond to a request for comment.

Physical Therapy

A medical biller for several physical therapists in the northeast told The Capitol Forum that they bill around $400 for an hour long out-of-network follow-up visit which, the biller said, is a rate many insurers accept. That means that a patient covered by a health plan with out-of-network benefits can meet a $1,200 deductible in three visits because, for each visit, the plan credits a $400 allowable rate towards the deductible. After the deductible is met, for a plan that has a 60/40 split between the health plan and patient, the plan will pay $240 of the bill leaving the patient to pay the remaining $160. So, a patient covered by a plan that has a $400 allowable would pay $2,320 for 10 follow-up physical therapy visits.

But for claims processed by Multiplan, the allowable rate is set at $151. The patient is still obligated to pay the provider $400 every visit but, since only $151 applies towards the deductible, it would take eight visits to meet a $1200 deductible. After the deductible is met, for a Multiplan-affiliated plan that is a 60/40 split between plan and patient, the plan only pays $91 for each visit, leaving patients to pay the remaining $309. So, 10 follow-up physical therapy visits would cost a patient covered by a plan that uses Multiplan close to $3,800.

That type of jump in out-of-pocket costs for patients can damage the relationship between the patient and healthcare provider and can cause patients to grow frustrated with their employer who provides the insurance.

The medical biller explained that she started seeing the drop in allowable for certain plans at the beginning of 2021. The allowable rate was reduced by Data iSight, Multiplan’s repricing service, and that she has not seen any negotiated offers. She said she has been making a lot of calls to Multiplan and Data iSight and Viant, which are companies under Multiplan’s umbrella, to ask questions and to help her patients get the benefit of the higher premiums they are paying for health plans with out-of-network benefits.

It is a challenge, she said, because the Multiplan representatives only allow her to ask five questions per call whether they can answer the questions or not.

Addiction Treatment Centers

An executive at a company that manages billing for addiction treatment centers located in multiple states told The Capitol Forum, “Multiplan is not the worst offender, Viant is much worse!” Although her company has dealt with Multiplan and Viant for years, she was unaware that Viant is a Multiplan company. Several sources who spoke to The Capitol Forum were under the impression that Viant, Medical Audit and Review (MARS), Data iSight, and Multiplan were unrelated companies.

The addiction treatment center biller said she “feels defenseless against [Multiplan and Viant].” She added that her peers in the addiction treatment industry feel the same way.

An example provided by the biller shows a negotiated offer from Viant on a claim for two days of intensive outpatient group therapy at three hours a day. The patient’s plan, which is managed by United Healthcare “states it pays 80% of usual and customary rates,” she said. “I averaged the out-of-network amount we see for the same service from UnitedHealth plans that have the same usual and customary rate language and don’t use Viant. The average comes to $924.”

The claim was billed at $3,700. Viant offered $323.58, according to the redacted negotiated offer reviewed by The Capitol Forum.

Some insurers actually publish their allowable rates, she said. “We have asked on multiple occasions how [Multiplan and Viant] determine what gets sent out for pricing,” she said. “They will not divulge what their methodology is. Typically, we get a representative who says they have no control over what gets sent out for Multiplan pricing.”

“When we reject a negotiation, it takes months to get any payment and we never get paid more than the amount on the negotiation offer. Anytime we say no, we are stuck waiting for payment.” She added that sometimes she noticed “for the same patient and the same provider, one claim will be priced by Multiplan and a different claim is priced by the payor. We’ve called on these before and were informed that the higher priced claim was incorrect, and a recoupment will follow.”

The addiction treatment industry overall has actually been dealing with concerns about Multiplan for years. In a 2016 article in Sober World, an owner of California addiction treatment centers wrote, “As the major insurance companies don’t like paying for effective addiction treatment, they are using companies owned by Multiplan to reprice California’s small, non-medical treatment facilities using irrelevant data from Medicare.”

In recent years, addiction treatment providers have filed numerous lawsuits against Multiplan and insurers for underpaying claims. The cases are in active litigation.

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Cosmetic surgeries have become increasingly popular in recent years, offering individuals the opportunity to enhance their physical appearance and boost their confidence. Embarking on the path to aesthetic enhancement through cosmetic surgery is a significant decision that warrants careful consideration. Two key factors that can make or break the success of your transformation are the choice of a cosmetic surgeon and knowing your options when it comes to anesthesia. Researching and selecting the right surgeon can be a transformative step toward achieving the desired results and ensuring a safe and satisfying surgical experience.

Before entrusting someone with your appearance, it’s essential to verify the credentials of potential cosmetic surgeons. Look for board certification, which signifies that the surgeon has undergone rigorous training and adheres to high professional standards. Additionally, check for memberships in reputable medical societies related to cosmetic or plastic surgery and check with the medical board for any citations, history of death, or any criminal records that the surgeon may have.

Different cosmetic surgeons have varying areas of expertise. Research surgeons who specialize in the specific procedure you’re considering. An experienced surgeon in a particular field is more likely to deliver optimal results and handle any potential complications with skill and confidence. Be aware of general surgeons advertising themselves as cosmetic surgeons. Schedule consultations with potential surgeons to discuss your goals, express concerns, and assess the surgeon’s communication style. Pay attention to how well the surgeon listens, explains procedures, and addresses your questions. A positive and open doctor-patient relationship is crucial for a successful cosmetic surgery journey. Ensure that the surgical facility where the procedure will take place is accredited. Accreditation indicates that the facility adheres to stringent safety and hygiene standards. Your safety during the surgical process is paramount, and choosing a well-equipped and accredited facility is a fundamental part of that commitment. Surgeries are only safe when performed by a surgeon at a surgery center. It would be unsafe or potentially cause the patient’s death if the surgery is performed at a medical office.

One other crucial decision lies in the choice of anesthesia—local or general. While local anesthesia may seem like a less invasive option and more affordable, it’s essential to understand the associated risks and why general anesthesia may be a safer choice for certain cosmetic surgeries.

Local anesthesia involves numbing a specific area of the body, rendering it insensitive to pain during a surgical procedure. For minor cosmetic interventions like injectables or minor facial enhancements, local anesthesia may seem like a convenient choice. However, the temptation of consciousness during a more extensive surgery may come with its own set of risks. Under local anesthesia, patients remain conscious during the procedure, potentially causing anxiety and discomfort. Watching a surgery in progress, even if pain-free, can be mentally distressing for some individuals. Local anesthesia may not provide adequate pain control for more invasive procedures. This could lead to discomfort or even pain during the surgery, impacting both the patient’s experience and the surgeon’s ability to perform optimally. Achieving complete anesthesia in a specific area can be challenging. Factors like individual pain tolerance, variations in anatomy, and unforeseen complications may result in inadequate numbing, leading to unexpected pain during the procedure.

In contrast, general anesthesia induces a state of unconsciousness, ensuring a painless and controlled environment allowing the patient to remain completely unaware and pain-free throughout the surgery. While it may seem like a more invasive option, general anesthesia offers several advantages that contribute to a safer and more controlled surgical environment. General anesthesia ensures the patient is entirely unconscious, eliminating any potential discomfort or psychological distress associated with being aware during surgery. This is particularly beneficial for complex and lengthy cosmetic procedures. With general anesthesia, pain management is more effective as it targets the entire body. This is crucial for minimizing post-operative pain and ensuring a smoother recovery process. Surgeons can perform cosmetic surgeries with greater precision and focus when the patient is under general anesthesia. This is especially important for intricate procedures that require meticulous attention to detail.

If the surgery is performed at a surgery center, the specialized team of anesthesiologists, nurses and surgical technicians will have the authority to force the surgeon to immediately stop the surgery if the surgeon becomes negligent or left out an important step. But if this surgery is performed in the surgeon’s medical office under local anesthesia, no one will have the authority to stop the surgeon from performing the surgery. Simply put, when performing surgery under local anesthesia, the surgeon will perform and make all the decisions without the opinions and professional witnesses of the team of anesthesiologists, nursing staff, surgical technicians.

Embarking on a cosmetic surgery journey is a personal and transformative experience, and choosing the right surgeon is a critical step in ensuring a positive outcome. By investing time in thorough research, checking credentials, reading reviews, and attending consultations, you empower yourself with the knowledge needed to make an informed decision. The right cosmetic surgeon will not only possess the technical skills required for your chosen procedure but also share a commitment to your safety, well-being, and overall satisfaction.

While local anesthesia may seem like an appealing option for its perceived simplicity and lower cost, the risks associated with inadequate pain control, patient discomfort, and the potential for incomplete anesthesia cannot be ignored. General anesthesia, on the other hand, offers a more comprehensive approach, ensuring patients are completely unconscious, and pain-free, allowing surgeons the precision required for intricate cosmetic procedures.

Ultimately, the choice between local and general anesthesia depends on the type and complexity of the cosmetic surgery. It is crucial for patients to engage in open and thorough discussions with their surgeons to determine the most appropriate anesthesia option, taking into account both the nature of the procedure and individual health considerations. Prioritizing safety and comfort will contribute to a positive cosmetic surgery experience and a smoother recovery journey.

Remember, your aesthetic journey is unique, and selecting a surgeon who aligns with your goals is key to achieving the confidence and satisfaction you desire.

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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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