Multiplan and Out of Network Pricing

[dish2501]

Interesting read about how insurers use Multiplan to negotiate out of network payments and how the providers and patients are losing out, while the payers and Multiplan rake in money. www.nytimes.com/2024/04/07/us/health-insurance-medical-bills.html?unlocked_article_code=1.ik0.cBTm.6yU6g2XAnVYP&smid=url-share

[sent]

I will read this and come back with some thoughts as this topic really irks me as a patient and a doctor in the system. I’m just tired of being constantly hoodwinked by the industry and I always feel depressed when I read yet another way a third party tentacle has extracted money out of the system with no benefit.

[Poppy]

Yeah, I was going to say I feel like our dental insurance has taken a real turn for the worse in the last few years. I wonder if the same thing is happening.

From what I can gather it mostly impacts employer self insured plans? Hopefully this will give them leverage to put a stop to the practice.

This is a hot mess and I hope this article (or something else) helps get the wheels in motion to put an end to this.

[sent]

Oh wow. Two parts of this article really stood out to me.

One was that private equity is involved in getting Multiplan employees to do the dirty work and negotiate down what the insurer pays the doctor. Private equity seems to make everything they touch absolutely disgusting in so many ways.

The other part was this quote. "Regulators rarely intervene. The administration of employer-funded health plans is mostly exempt from state regulations. Enforcement primarily falls to an agency within the federal Department of Labor, which says it has one investigator for every 8,800 health plans."

So there are two kinds of health plans. Self-funded plans versus fully-insured plans. I always mix up which plan is which. Now I'm going to remember. The fully-insured ones are the plans that are subject to state laws about insurance. The self-funded plans which are the ones described in the section I quoted above, are exempt from state laws and and fall under ERISA. This is important because sometimes we run into a roadblock where the insurance company just refuses to pay us properly despite us doing everything correct on our end. And then we can't complain to the state insurance commissioner because it's a self-funded plan so the state insurance commissioner can't control anything about that plan. Now I know there is 1 investigator for every 8,800 plans at the DOL. I need to figure out how to get further into complaining at the DOL level. I'm not sure how I'm going to do it and it might take me a few years, but I didn't even know this little nugget of info so thank you for sharing this.

Basically the system is so very very broken. How do we even begin to fix this?

[sent]

Apr 8, 2024 20:21:56 GMT -5 Poppy said:

Yeah, I was going to say I feel like our dental insurance has taken a real turn for the worse in the last few years. I wonder if the same thing is happening.

From what I can gather it mostly impacts employer self insured plans? Hopefully this will give them leverage to put a stop to the practice.

This is a hot mess and I hope this article (or something else) helps get the wheels in motion to put an end to this.

The negotiation by Multiplan doesn't happen so much with dental insurance claims. I've been out of network with various plans over the years and I've only once ever seen a letter asking me to take a lower fee for an out of network patient. I ignored it and the insurance company eventually sent the full fee according to their formula anyways. I have heard it happening with medical though. I've been wanting to try and bill medical insurance for dental things that medical plans say they cover so I've done a lot of research or this. I ask lots of dentists & specialists I meet if they've billed medical and to share insight. Some colleagues said they stopped billing medical because as out of network providers, they started getting the letters from Multiplan type places a few years ago. It became an enormous administrative challenge to fight the Multiplan corporations to get them out of the picture and get back through to Aetna/Cigna/whoever to pay the claim according to the insurance company's own formula. So they just stopped billing medical. 

[dish2501]

The whole industry is broken. A handful of companies and leaders are making bank while patients and smaller providers struggle.