Make me an offer: How third-party negotiators suppress out of network claims
As sensational as this title may sound, in August of 2023, AdventHealth brought an antitrust lawsuit against MultiPlan, Inc. a third-party business that negotiates out of network insurance claims between health care providers and insurance companies. The details of the lawsuit are available online.
AdventHealth refers repeatedly to the “MultiPlan Cartel.” I became familiar with MultiPlan last year after I resigned from the panel of an insurance company but continued to submit electronic claims on behalf of existing clients who had out of network benefits.
A small number of clients were granted authorization to be seen out of network to continue their care with me. Soon after submitting an electronic claim, I received my first email from MultiPlan letting me know that they were contracting as a third party on behalf of the insurer. The email stated that a member of the Negotiation Services team had analyzed the claim and issued an offer for my consideration.
By clicking on a link within the email, I was taken to the claim details which included a lowball offer of approximately half of what I had billed. Naively, as a first timer, I thought they may not be aware that I had a pre-authorization and promptly wrote back, noting that information.
Only a day later, I received another email, ignoring my prior comments, but offering me 20 percent more than the original offer. Was this a sophisticated artificial intelligence algorithm or might there be an actual human “member of the Negotiation Services” team?
Intrigued, I responded again to see what would happen. The message within indicated that payment would be “released” within 15 days if I accepted their offer. I took this to mean that if I did not accept the offer, payment would be held hostage and might not be forthcoming in the near future. The vision of Marlon Brando ensued, “Make ‘em an offer he (or in this case she) can’t refuse”
The process of negotiating back and forth on claims felt like a shakedown bordering on the ridiculous. Sam-I-Am, the antagonist in Dr. Suess’s “Green Eggs and Ham” book would have been an excellent member of the Negotiation Services Team. Would I like them in a box? Would I like them with a fox?
Following the email barrage, the second siege consisted of telephone calls. Warily, I picked up a call from the third-party negotiator, a person I will refer to as the Persuader. Thinking again of Sam-I-Am’s final plea, “You do not like them, so you say. Try them, try them and you may! Try them and you may, I say!”
The Persuader had a powerful bullet in the chamber. She focused on the impact on my patient. She appealed to my sense of guilt and explained that my client would have less to pay out of pocket if I was to accept their offer. The verbiage in the agreement stated that the provider who accepted the “expedited amount” would not waive the difference between the fee and the expedited amount for the patient.
The negotiation offers from MultiPlan via email required quick turnaround time. The model seems built on the premise that no provider has the time or staffing to respond quickly to such offers. The underlying threat seems to be that if you do not agree, they may cut the price even further.
The lawsuit alleges that MultiPlan is in violation of the Sherman Antitrust Act, legislation originally passed in 1890, to prohibit independent businesses from colluding to take over a market and manipulate the price of services or products.
The “conspirators” named in the AdventHealth lawsuit include many of the major American health insurance companies. As a practitioner close to retirement, dealing with third-party negotiators is a hassle but doesn’t faze me.
Solo practitioners in the early stages of their career often do not have the cashflow to withstand onslaught from a third party that holds payment hostage unless the practitioner agrees to a substantial underpayment. The practice of third-party negotiation is both coercive and suppresses utilization of out of network benefits.