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Latest Corporate Intermediary Scam, For Out-of-Network Charges

Here’s the latest corporate innovation to extract resources from health care, by creating yet another inefficient but highly profitable intermediary. This time it’s for out-of-network charges. Who pays more? Patients.

April 8, 2024

Insurers Reap Hidden Fees by Slashing Payments. You May Get the Bill.
The New York Times
April 7, 2024
By Chris Hammy

MultiPlan is a little-known data analytics firm that works with UnitedHealthcare, Cigna, Aetna and other big insurers to decide how much so-called out-of-network medical providers should be paid. It promises to help contain medical costs using fair and independent analysis.

But a New York Times investigation, based on interviews and confidential documents, shows that MultiPlan and the insurance companies have a large and mostly hidden financial incentive to cut those reimbursements as much as possible, even if it means saddling patients with large bills. The formula for MultiPlan and the insurance companies is simple: The smaller the reimbursement, the larger their fee.

Here’s how it works: The most common way Americans get health coverage is through employers that “self-fund,” meaning they pay for their workers’ medical care with their own money. The employers contract with insurance companies to administer the plans and process claims. Most medical visits are with providers in a plan’s network, with rates set in advance.

But when when employees see a provider outside the network, many insurance companies consult with MultiPlan, which typically recommends that the employers pay less than the provider billed. The difference between the bill and the sum actually paid amounts to a saving for the employer. But, the Times found, it means big money for MultiPlan and the insurer, since both companies often charge the employer a percentage of the savings as a processing fee.

In recent years, the nation’s largest insurer by revenue, UnitedHealthcare, has reaped an annual windfall of about $1 billion in fees from out-of-network savings programs, according to testimony by two of its executives. Last year alone, MultiPlan told investors it identified nearly $23 billion in bills from various insurers that it recommended not be paid.

The little-understood financial incentive for insurers and MultiPlan has left patients across the country with unexpectedly large bills, as they are sometimes asked to pick up what their plans didn’t pay. In addition, providers have seen their pay slashed, and employers have been hit with high fees. In some instances, the fees paid to an insurance company and MultiPlan for processing a claim far exceeded the amount paid to providers who treated the patient.

After MultiPlan’s founder sold it to private equity investors in 2006, the company pursued a more aggressive approach. It embraced pricing tools that used algorithms to recommend lower payments, and no longer protected patients from having to pay the difference.

Once insurers were no longer obligated to use the nonprofit database, FAIR Health, they began looking for ways to combat billing and other charges they considered egregious. Insurers contended that overbilling would skew payments too high. Cigna: “We need someone external to Cigna to develop acceptable rates.” UnitedHealthcare emphasized companies still using FAIR Health, “understand they don’t want to be on that program anymore.”

UnitedHealthcare had a big incentive to encourage this change. When it processed claims from employer plans using FAIR Health, the insurer collected no additional fee. But when it used MultiPlan, it typically charged employers 30 to 35 percent of the difference between the billed amount and the portion paid.

MultiPlan, too, charged a percentage of the savings, meaning it could make more by recommending lower payments. (FAIR Health charged a flat fee.)

While UnitedHealthcare was MultiPlan’s largest customer, Cigna and Aetna also embraced its tools and fee model. Other insurers that work with MultiPlan include Kaiser Permanente, Humana and some Blue Cross Blue Shield plans. Employers with self-funded plans administered by insurers include large companies like Coca-Cola and AstraZeneca and smaller organizations like school districts and union locals.


Comment by: Don McCanne & Jim Kahn

Theoretically, health insurance should allow us to equitably pool our funds in order to make health care both accessible and affordable for everyone participating. We have had a goal to expand that to include everyone. However, we have relied heavily on the private insurance industry which has engaged in business activities designed to increase profits for its shareholders and compensation for its executives. These activities have impaired access and resulted in an increase in medical debt for those for whom the system should be designed: the patients.

Not only are the insurers placing financial pressures on the physicians, hospitals, nursing homes and the many other providers of health care services, but they have also been attempting to further increase their incomes through increases in insurance premiums, deductibles, copayments, excessive prior authorization requirements, narrow provider networks, and limitations in coverage. Frequently these are applied in a manner that denies patients needed care, care that they can usually obtain if they are enrolled in a government program such as Medicare, Medicaid, VA Health if their particular program has not been overly privatized.

So what is the insurance industry offering us now? An example in the article: The physician provides medical services and bills $1000 for them. The self-insured employer pays the fee determined by MultiPlan which is only $200 of the $1000. The amount “saved” for the employer is $800 of which MultiPlan receives 7% or $56 and the insurer receives 35% or $280. A $800 balance remains which “the patient is potentially on the hook for.” Whether the patient or the physician is out the remaining $800 of the medical bill, clearly the insurers are no longer fulfilling what we consider the traditional function of insurers, yet they are leaching much of our health care dollars for worthless functions.

This is yet another intermediary strategy to extract profits. This time it focuses on out-of-network charges (those unregulated by the “No Surprises” Act). The “business model” is to add complexity via inserting extra corporate actors in a previously simpler arrangement. Just like Pharmacy Benefit Managers insert themselves between drug companies and pharmacies. They promise savings, but actually increase costs. This removes resources that should be spent on health care, and redirects them to shareholders of for-profit entities. Patients pick up the slack.

We’ve long said that it is time to get rid of the private insurers and their add-on leaches, and this development seems to make it even more of an imperative. It is high time to improve Medicare and to expand it to cover everyone as a single payer system that is equitably funded through progressive taxes.

Of the multitude of New York Times reader comments for this article the most popular was by a Canadian physician commenting on their single payer system who wrote, ”The US needs to get their act together.

About the Commentator, Don McCanne

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Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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