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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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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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Insurance Companies are Being Sued by a Surgery Center that Had Enough

After being owed over $6M, Coast Surgery Center has had enough and is suing the insurance companies.





Jan 16, 2023, 06:35 ET

HUNTINGTON BEACH, Calif., Jan. 16, 2023 /PRNewswire/ — Coast Surgery Center is an outpatient surgery center in the city of Huntington Beach, CA and has been in business since 2018. Coast is a facility for outpatient procedures offering healthcare related services. Just like most medical facilities, before services are rendered to a patient, the provider and facility obtain authorization with the insurance carrier for approval and are provided with the usual, customary, and reasonable (UCR) rate for the procedure. Based on the UCR rate provided by the insurance, the provider and patient understand that if they are to proceed, how much the insurance company will reimburse. All the information obtained is documented by both the insurance carrier and facility as a part of their policy and practice.

Coast provides services to its patients relying on the insurance representations solely based on their statements, promises, and representations. By authorizing a procedure, insurance companies are granting Coast to provide healthcare services to their members, and Coast is fulfilling the insurances’ contractual obligations to its members.

The insurance companies significantly started reducing the reimbursement rate from UCR to below Medicare rate in 2018, and for some claims, they didn’t pay at all. Since 2019, Coast Surgery Center accumulated bills totaling over $6M. So now Coast is suing some of the largest health insurance providers in the country; United Health Care, Cigna, Aetna, Anthem Blue Cross of California, Blue Shield of California, Blue Cross Blue Shield Associates, and all Blue Cross Blue Shield affiliated companies for illegal, coercive, unfair, fraudulent practices, bad faith and deceptive advertisements.

In the civil case #30-2022-01271476-CU-CO-CJC filed by Coast Surgery Center in Orange County, California, Coast states they billed Blue Cross $49,550 for a surgery and Blue Cross paid $202.99. This is an example for many of the underpaid bills. Insurance companies have had a history of lawsuits for underpaying. As of June 30, 2019, 43% of Anthem’s medical bills were unpaid. By 2021, that figure rose to 53%, resulting in a total of $2.5 billion unpaid bills. Yet, Anthem’s profits in 2020 were reported to be $4.6 billion and $3.5 billion in the first half of 2021.

These unpaid bills harm medical providers like Coast by failing to provide reasonable rates for its services, negatively impacting the quality of service, value of Coast, and significantly impacting Coast’s business relationship with patients and prospects. With this lawsuit, Coast is hoping that the big insurance companies will stop taking advantage of small providers as Coast will continue to provide critical, quality healthcare services and treatment to its Defendants’ members on its behalf and hope to be paid reasonable rates.

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MultiPlan’s ‘Maybe You’re In-Network’ PPO Product May Violate No Surprises Act, Experts Say 




Published on Apr 28, 2022 by The Capitol Forum

MultiPlan’s (MPLN) products for health plans fall under two umbrellas—a preferred provider organization (PPO) network product and products related to payment editing, negotiating, and repricing of healthcare claims.  

The Capitol Forum has previously reported about the company’s editing, negotiating, and repricing services. 

MultiPlan’s PPO product lets health plans rent Multiplan’s networks as a primary network or as a complementary “wrap” network to extend a plan’s established network. 

For its PPO product, MultiPlan contracts with healthcare providers to set agreed-upon payment rates for the providers’ services. The providers gain access to members of health plans that are MultiPlan clients and agree not to balance bill the members. Separately, MultiPlan contracts with health plans so the plan members can receive services from MultiPlan PPO providers at the rates agreed to in the contracts between MultiPlan and the providers. 

But, according to the Capitol Forum’s ongoing investigation, MultiPlan allows clients to disregard the PPO contractual rates and pay claims at lower rates. MultiPlan’s clients can choose this option after services have been rendered and on a claim-by-claim basis. The provider and the patient are kept in the dark until after the claim has been processed. If the plan decides to pay less, the transaction shifts from an in-MultiPlan-network service to one that is considered out-of-network, meaning providers are no longer prohibited from balance billing and the patient may be surprised by unexpected balance bills.  

MultiPlan’s PPO product is essentially a “maybe-you’re-in-network” PPO offering, although providers and patients think that services are being offered in-network. 

MultiPlan’s strategy to let clients opt out of contractually agreed-upon rates was implemented, seemingly unilaterally, beginning in late 2015. 

Does MultiPlan’s “maybe-you’re-in-network” PPO product violate the No Surprises Act? The US Department of Health and Human Services is set to implement a new rule under the No Surprises Act that will require providers and health plans to provide specific cost and payment breakdowns for the patient in advance of healthcare services. Such a rule would likely prohibit MultiPlan’s “maybe-you’re-in-network” PPO product, because patients getting treatment from “maybe-in-network” providers don’t find out information about the service—whether it was in network, the costs, co-pays, etc—until after the service is provided. 

The No Surprises Act went into effect in January of this year, and companies are supposed to make good faith efforts to honor the law. But several provisions are not expected to be enforced until 2023 because HHS Secretary Xavier Becerra has not yet issued rules to implement those provisions, according to Jack Hoadley, Research Professor Emeritus in the Health Policy Institute of Georgetown University’s McCourt School of Public Policy. 

Statement from Multiplan. A MultiPlan spokesperson provided the following statement: 

“We stand behind our mission to deliver affordability, efficiency and fairness to the US healthcare system. Our solutions provide a strong value proposition to payors, health plan sponsors and members, as well as to providers. All of our pricing methodologies are fair, transparent and reasonable. 

“MultiPlan has a diverse base of payor clients (and their customers) that access all or some of our network-based, analytics-based and payment and revenue integrity services to support a variety of plan configurations. This flexibility enables significant innovation, helping providers see more patients, and giving payors more tools to manage health care costs and in turn reduce their members’ out of pocket costs. 

“Regardless of which out of network pricing methodology or methodologies our customers request that we use to price a claim, our pricing amounts are always recommendations to the healthcare payor. Clients ultimately decide what to pay the provider based on their benefit plan design and established payment policies.” 

Analysis of Statement. MultiPlan, in its statement, appears to distance itself from responsibility by saying decision-making is left entirely up to clients that pay health claims. MultiPlan’s statement also does not directly address specific questions about MultiPlan’s PPO asked by The Capitol Forum

MultiPlan PPO Networks Background 

Health plans can rent MultiPlan’s network of providers as a primary network or as a complementary or “wrap” network. 

MultiPlan clients pay a flat fee or a percentage of savings fee to access MultiPlan’s networks, according to the company’s recent annual filing.  

MultiPlan’s primary networks. When a health plan does not have its own network of providers, MultiPlan’s PHCS network functions as a primary network for a flat fee. MultiPlan also says some Medicare Advantage and Medicaid plans “outsource some portion of their provider network development to MultiPlan.” 

Multiplan’s complementary, or “wrap” networks. Plans that have their own established network use MultiPlan’s networks as a “complementary” or “wrap” network. Clients pay MultiPlan a percentage of savings fee to access the complementary network. But when a client opts a claim out of the network, the client pays nothing to MultiPlan.  

The clients who use the complementary network most commonly include large commercial insurers; property and casualty (workers’ compensation and auto medical) carriers via their bill review vendors; Taft-Hartley (labor union bargaining agreement) plans, health system-owned plans, independent plans, and some third-party administrators who process claims for employer-funded plans. MultiPlan says in the filing that complementary networks operated “under the health plan’s out-of-network benefits, or otherwise can be accessed secondary to another network.”  

Starting in 2015, MultiPlan intentionally undermined its participating provider agreements. Since at least 2011, some insurer clients were opting out of MultiPlan contracts on a claim-by-claim basis when they wanted to pay less than the rate in the agreements between providers and MultiPlan, according to provider correspondence with MultiPlan reviewed by The Capitol Forum. But the practice appears to have been a violation of the providers’ contracts with MultiPlan.  

So, in 2015 MultiPlan quietly took a series of steps to unilaterally “update” providers’ contracts to give clients legal cover for ignoring MultiPlan’s participating provider agreements. 

In letters sent to providers in late 2015 and early 2016, MultiPlan told providers that there were several conditions under which MultiPlan’s clients would not be obliged to honor the terms of providers’ MultiPlan network agreements. Most importantly, “If the benefit plan or reimbursement policy sets a maximum amount the plan will pay, the terms of your agreement may not apply to a specific claim if the agreed contract rate for that claim is above the maximum amount,” Bruce Singleton, MultiPlan senior vice president of network development strategy, wrote in the letter.  

This change meant that if an insurer wanted to set a rate lower than a provider’s MultiPlan PPO contracted rate, the insurer could refuse to access the network, apply their own rate instead, and leave the patient with the rest of the bill. Providers and patients who were expecting the patient’s liability to be contingent upon the provider’s MultiPlan contractual rates would be in for a surprise if the health plan opted out of the network.  

In some letters, Singleton gave the impression that providers could accept or reject the update because he asked providers to confirm their agreement with the terms outlined in the letter by signing off on the changes. 

But MultiPlan imposed the changes regardless of whether providers rejected the changes or not, according to correspondence and other documents filed in several lawsuits against MultiPlan, reviewed by The Capitol Forum

One of the facilities that explicitly rejected the changes was Sarasota County Public Hospital District, according to deposition testimony and exhibits presented during litigation the facility brought against MultiPlan and insurance carriers. “We are in receipt of a letter from MultiPlan in regards to changes in the agreement…We dispute this letter in its entirety,” the facility wrote to MultiPlan in January 2016. 

MultiPlan implemented them anyway, according to Sarasota’s allegations. The case settled before trial. 

In another lawsuit against MultiPlan, the attorney for a provider group who objected to the changes in Singleton’s letter questioned Singleton exhaustively about the letter during a deposition. Singleton explained during the deposition that the decision to send the letter originated with MultiPlan’s legal department which had tweaked the language in the letter for three to six months with input from the company’s network development and healthcare economics departments before it was sent to providers.  

Singleton also testified that MultiPlan decided to send the letter to several thousand providers throughout the country whose charges were at or above 500% of Medicare’s rates. Singleton’s deposition was taken during litigation against MultiPlan by a New York bariatric surgical group. The facility lost in the lower court and has filed an appeal, which is pending.  

Separately, in a deposition taken during the Sarasota litigation, MultiPlan executive Shawn McLaughlin testified that Singleton’s letter “was intended to be on the forefront of transparency, to let our providers know that there were changes happening with our clients that were going to happen whether they signed this letter or not, and this was an attempt to get acceptance from the provider community…”  

In addition to the letters, MultiPlan also updated its template provider agreement in 2015 to include the new language, according to an exhibit filed in New York case. And, as Singleton noted in his letters, contemporaneous to sending providers the letter, MultiPlan revised its “administrative handbook(s) to include the same updates and clarifications.”  

Further, in addition to the letters, the template, and the handbooks, MultiPlan began including new language in amendments to its provider contracts. 

According to documents filed in recent lawsuits reviewed by The Capitol Forum, Multiplan amended PPO providers’ contracts, specifically related to Multiplan’s client access to complementary networks. 

MultiPlan has been relying on the changes detailed in the letter, the handbook, and the contract amendments as defenses to allegations of underpayment in several recent lawsuits brought by doctors and facilities, reviewed by The Capitol Forum.  

Many providers, ranging from large and well-funded companies like TeamHealth to small providers’ offices and facilities, have signed off on MultiPlan’s letters or contract amendments without fully grasping the implications. 

Expert discusses how the No Surprises Act addresses MultiPlan’s “maybe-you’re-in-network” PPO Product. Jack Hoadley, a research professor emeritus in the Health Policy Institute of Georgetown University’s McCourt School of Public Policy, explained how the No Surprises Act may cover MultiPlan’s misleading conduct in its PPO plans: 

“From the point of view as consumer protection there is a new element with the No Surprises Act that went into effect at the beginning of this year. 

“There is a lot of depth in this law. I think some of the details have flown a bit under the radar. With implementation starting this past January, we’ve seen a significant amount of publicity around the core protections about emergencies and being billed by out-of-network providers who see patients at in-network hospitals. Over the next year, as we get to more rulemaking and the full enforcement in 2023, I do think we are going to continue to hear more about some of these other provisions. I think there is a lot more that consumers, providers, and insurers are going to need to understand so that the consumers benefit, and the providers and insurers stay in compliance with the law. 

“The No Surprises Act [NSA] is the law, but some provisions are not going to be actively enforced yet. There’s delayed enforcement for some areas of the law. 

“For services where the NSA’s balance billing prohibitions do not apply, patients are now eligible, under the NSA, to get pre-service advance explanation of benefits [AEOBs]. Providers are required to provide information on what it will cost the consumer out-of-pocket in advance of the service.  

“So, that’s going to have an effect on this notion of insurers being able to change the rules after the claim is submitted because if the patient gets that AEOB notice and then it changes, it will have an impact on the patient as well as the provider. 

“The AEOB provision has not been fully implemented in the sense that the rules have not been written on this for insured patients. There are rules for AEOBs for uninsured patients. As far as rules for insured patients, there is rulemaking to come later this year but the law itself is already in effect and insurers are supposed to make good faith efforts to comply with this. It won’t be enforced until 2023. 

“The idea for AEOBs is that a provider, who is scheduling a service with a patient—whether it’s in a facility or in a provider’s office or in-network or out-of-network—has to submit information to the health plan. The plan is supposed to send written information about the financial breakdown of what the insurer will pay, what the provider will be paid by the insurer, and the amount the provider is allowed to charge the patient in cost sharing. The intent is that patients can make an informed decision and decide if they want to try to find a more affordable option.” 

The intent of this provision, Dr. Hoadley explained, is that patients are provided with transparency and actual dollar figures, not some vague references to “usual and customary,” or “based on prevailing rate,” or “proprietary database calculations.” But he emphasized again, “until the rulemaking is done, the details of what exactly will be required hasn’t been formalized yet. The intent of this law is that, before a service is provided, patients will know what their financial obligation will be after their insurance is taken into account.” 

Dr. Hoadley continued describing the intent behind the AEOB provision: 

“It’s a good faith estimate, it’s not that the insurer is committing to the estimate. But certainly, there are going to be issues if a plan wants to decide differently after a service has been provided and say, ‘Oh no, we are no longer treating this the way we were in the AEOB. So, instead of your bill being $425, it’s going to be $800.’ There’s not a specific legal remedy in the law, but I think it will certainly put some additional leverage on the situation to have the financials settled before the service is delivered. 

“There is an enforcement aspect to this in the law but, at least initially, it deals with whether the AEOB was provided or not.  

“This provision will apply to employer funded plans and employer fully insured plans as well as plans purchased on the individual market. 

“I would hope that the rulemaking will address what happens if circumstances change. Of course, there are legitimate reasons for an increase in out-of-pocket costs actually owed compared to the AEOB, such as scheduling the service in December and the patient had met their deductible but there is a delay and the service actually takes place in January when the deductible starts over from zero because it’s a new plan year. Another reason could be if complications arose during a procedure. 

“But as a policy person, if a plan sends an AEOB based on the assumption that a service would be treated as in MultiPlan’s network and then they changed their mind after the service was provided, I certainly as a patient would be in an uproar. I would hope that the rulemaking would address that and make it clear that is not a reasonable adjustment.  

“The whole idea is to give patients the chance to know what they’ll owe. And if they think it’s more than it ought to be, then they have the chance to go talk to other providers to compare prices. This provision in the NSA is about a well-informed consumer—whether you are going to comparison shop or just be prepared for the amount you are going to be responsible for paying. 

“So, while this provision wasn’t written with the MultiPlan behaviors in mind, it certainly is written to the basic idea of no surprises. Mostly we think of that related to balance billing in emergencies or hospitals, but, as the lawmakers wrote this, it was about other kinds of situations too.” 

Dr. Hoadley also discussed another provision in the No Surprises Act regarding network accuracy and incorrect provider information: 

“What do you do if a health plan’s provider directory says Dr. Smith is in the network and it turns out that Dr. Smith is not in the network?  

“The NSA limits cost sharing to the amount that would have been applied if the provider was in network if the enrollee demonstrates that they relied on the health plan’s provider directory and that information turned out to be incorrect. In this situation, the patient will only owe their in-network cost sharing.  

“So, if MultiPlan lists a provider as in network and you make a decision based on that, then you as the consumer should be protected. It doesn’t speak to what the provider will get but the consumer should be protected.” 

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