Major insurers made millions in fees by using MultiPlan, a data analytics firm, to determine how much to pay providers for out-of-network claims, according to an investigation from The New York Times.
MultiPlan helps plans handle out-of-network claims, advising insurers what to pay providers. According to the Times, the plans often pay much less than providers bill — and charge self-funded employers a percentage of the savings as a processing fee. The formula incentivizes payers to pay providers less so they can charge employers higher fees. Meanwhile, patients are potentially responsible for the remainder.
Some patients interviewed by the Times were left with large medical bills after insurance did not pay the full out-of-network cost.
UnitedHealthcare has made $1 billion in fees annually from out-of-network savings programs, according to the report. Aetna and Cigna have also made millions from the fees, according to the Times.
A New Jersey trucking company interviewed by the newspaper received a $50,000 fee from UnitedHealthcare on a single hospital bill.
The investigation, published April 7, was based on confidential corporate records, legal filings, claims information and more than 100 interviews, including with former MultiPlan employees.
In an April 8 statement, MultiPlan said it "fundamentally disagrees" with its depiction in the article. MultiPlan customers rely on the company to avoid costly negotiations with providers, it said in its statement.
"The article misses the fundamental economics of the healthcare system, in particular, out-of-network healthcare services pricing, and resultant claims processing and adjudication and the sources of balance bills in the out-of-network realm," the company said.
UnitedHealthcare, Cigna and Aetna told the Times in separate statements MultiPlan helps them control costs for employers. Providers often charge "egregious" out-of-network prices, a UnitedHealthcare spokesperson told the Times. Cigna told the outlet some providers are charging rates more than 1,000% of Medicare rates for out-of-network claims.
"We have comprehensive networks of credentialed participating providers in every specialty who agreed to provide covered services at competitive negotiated rates. Our provider networks provide the members and plan sponsors we serve with access to quality, affordable and convenient healthcare," an Aetna spokesperson told Becker's.
The report sparked calls from the American Hospital Association for an investigation into MultiPlan's practices.
The Labor Department is responsible for oversight of employer-sponsored health plans. The agency has one investigator for every 8,800 health plans, according to the Times.
"Even so, the AHA urges the Department of Labor to immediately open an investigation into these practices and hold companies like MultiPlan and its corporate commercial insurer partners to account for these unconscionable practices, distorted incentives, potential violations of ERISA, and ultimately, harms to American patients and employees," the association said in an April 9 letter to the department.
Becker's has reached out to UnitedHealthcare and Cigna for comment and will update this article if more information becomes available.
Read The New York Times' full report here.