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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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Published on Mar 07, 2022 – The Capitol Forum

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

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

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

Evidence of Anticompetitive Information Sharing

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

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

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

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

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

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

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

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

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

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

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

Antitrust Experts Analyze Information Sharing Evidence

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

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

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

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

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

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

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

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

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

Capitol Forum Analysis of Information Sharing Evidence

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

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

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

Evidence About Multiplan Hosting Health Insurance Executives at Company Meetings

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

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

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

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

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

Source: Redacted excerpt of a 2017 Multiplan document

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

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

Antitrust Expert Analyzes Hosted Meetings Evidence

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

Capitol Forum Analysis of Evidence Related to CAB Meetings

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

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