Welcome to this eye-opening episode of the VBCA Podcast, where we tackle one of the most pressing yet underreported issues in healthcare: hidden fees, surprise bills, and the alleged cartel controlling out-of-network reimbursements.
In this episode, host Alex Yarijanian breaks down the allegations against MultiPlan, a third-party repricing company accused of working with major insurers like UnitedHealthcare, Cigna, and Aetna to suppress out-of-network payments. We explore:
How MultiPlan's practices impact patients, providers, and employers.
The AMA’s antitrust lawsuit accusing MultiPlan of operating a cartel.
Real stories, like that of Kelsey Toney, a behavioral therapist forced to turn away patients due to unsustainable payment rates.
The staggering $19 billion providers lose annually to these practices.
If you’ve ever wondered why your healthcare bills are so high or why your provider suddenly stopped taking your insurance, this is the episode for you.
Key Topics Discussed:
What are in-network vs. out-of-network providers?
How does MultiPlan determine reimbursement rates?
The human cost of suppressed reimbursements for providers and patients.
Legal implications of the AMA and ISMS lawsuit against MultiPlan.
The broader impact on value-based care and healthcare transparency.
Takeaways:
Hidden fees in healthcare create a sense of unpredictability and financial anxiety for patients.
MultiPlan's involvement in processing out-of-network claims often leads to underpayment for healthcare providers.
Out-of-network providers typically charge fees that reflect their true cost of delivering services.
Patients frequently find themselves responsible for covering the difference in reimbursement rates from insurers.
Real-life patient stories underscore the profound human impact of rising healthcare costs and surprise bills.
The current healthcare system often prioritizes profit margins over genuine patient care and outcomes.
Companies mentioned in this episode:
MultiPlan
UnitedHealthcare
Cigna
Aetna
Research Links:
Legal Complaint (PDF): AMA v. MultiPlan Full Complaint - Filed in the United States District Court for the Northern District of Illinois involves the American Medical Association (AMA) and the Illinois State Medical Society (ISMS) as plaintiffs, suing MultiPlan, Inc. for alleged antitrust violations.
AMA Press Release - The American Medical Association’s press release discussing the antitrust lawsuit against MultiPlan.
Transcripts
Alex Yarijanian:
Hello everyone and welcome to the VBCA podcast where we cut through the noise, dig into the big question shaping healthcare today, and explore how value based care can actually deliver value, not just in theory, but in practice.
I'm your host, Alex Yarijanian and today we're pulling back the curtain on a practice that impacts millions of Americans but rarely gets the attention it deserves. I'm talking about hidden fees and surprise bills that make healthcare feel less like a service and more like an unpredictable gamble.
Imagine this, you're a patient who's done everything right.
You've purchased a solid insurance plan and that insurance plan promises flexibility, like being able to see doctors outside of your insurers network. You get treated, you heal and the bills start rolling in. What you thought would be a manageable expense suddenly balloons into a financial nightmare.
And in today's episode, we're going to unp how a company called Multiplan, which many of us are familiar with in the industry, working alongside some of the biggest names in the industry, in the insurance industry, which everybody would recognize, has been accused of creating a system where patients pay more, providers earn less and insurance, yes, Multiplan itself walks away with millions in profits. This is big. It's a story about fairness, transparency and trust. It's a story we all need to hear.
This particular episode is inspired by a lawsuit, long 171 page or so lawsuit against Multiplan alleging a cartel style monopoly and a chokehold over out of network reimbursement and that segment of the market. Let's start with the basics. For those that are unfamiliar with the terms in network and at a network, here's a quick breakdown.
You guys are going to need this. In network providers are those who have contracts with the insurance company.
So basically they agree these providers to provide services at a discounted rate. Okay. In return, the idea is that they get a steady stream of patients sent their way, right. Referrals. You're in network.
Now, out of network providers, on the other hand, they operate outside of that insurance network. They don't have pre negotiated rates with insurance companies, which means they charge what they believe reflects their true cost of service. Right.
That's why they didn't sign the discounted contract from the insurance company. That's why they're out of network.
Now many patients, you might have been one or had a loved one who wants to go to an out of network provider because of a number of reasons, including specialist access or services that aren't in that network of your insurance companies and insurers offer plans, for example, when we hear ppo, the idea is that there's a flexibility built into it so that you could go outside of that provider insurance network and be able to still get some insurance reimbursement. But here's the catch out of network claims are often reimbursed at much lower rates.
And insurers rely on companies like Multiplan to determine just how much or how little actually they should pay the providers.
So your insurance company contracts this other company called Multiplan to handle all those out of network claims, and this Multiplan gets to decide what rate they're going to pay. So this brings us to the heart of today's story.
According to a recent lawsuit, as I mentioned earlier, filed by the American Medical association and the Illinois State Medical Society, Multiplan, alongside other major insurers like UnitedHealthcare, Cigna and Etna, has allegedly created a system that underpays doctors, overcharges employers, and leaves patients to fill the gaps in what they call a criminal cartel. So how does Multiplan work? So who is Multiplan and why are they at the center of this controversy?
So Multiplan is what's known as a third party repricing service. So their job is to review out of network claims and recommend what they believe is a fair reimbursement rate. But here's the kicker.
Multiplan doesn't work for you, the patient or even the doctors. They work for the health insurance company. So here's how it works in practice. A patient goes to an at a network provider and receives care.
The provider then submits a bill to the insurance company that the patient has presented. Instead of paying the full amount, the insurer sends the bill to Multiplan for processing.
Multiplan then uses a proprietary algorithm to calculate that a reduced reimbursement rate. And it's far below the provider's initial charge. On the surface, this sounds like a way to keep healthcare costs down, right?
But according to critics and according to this lawsuit, it's a system that's ripe for abuse. Why? Because Multiplan charges a fee based on how much they save and for the listening public, save in air quotes how much they save the insurer.
That means the lower they push reimbursement rates, the more they the insurer profits. Right. It's a system that's been described as mafia like, with Multiplan acting as an enforcer.
They're pressuring doctors to accept pennies on the dollar for their services, while patients and employers foot the Rest of the bill. Let's put a human face on this issue. The New York Times and I'm going to put the notes on this link here. The show notes.
The New York Times recently profiled a behavioral therapist named Kelsey Toney who works with children on the autism spectrum in rural Virginia. Kelsey charges rates that align about with the Medicaid in that market, a program not exactly known for high payouts in the first place.
But when she built Meridian Health, which is an Aetna subsidiary, she was told that her services were worth less than half of those Medicaid rates, half of Medicaid's rates. As the only provider within an hour's drive, Kelsey faced an impossible choice.
Either turn away vulnerable patients who you've had a relationship with, you've been seeing for a while likely, and who need access in rural Virginia, or lose money on every visit. What decision will you make?
Ultimately, she decided she can't afford to keep seeing patients with that insurance company, leaving these families without critical care.
And then there's a story of Gail Lawson, a heart surgery patient hit with over a hundred grand in medical bills, over $100,000 in medical bills because her insurance, guided by Multiplan, reimbursed only a fraction of her surgeon's costs or charges. These stories aren't just exceptions. I mean, we can go on and on. They're symptoms of a system that prioritize profit over people.
And for every one story you hear, there's probably 90 to 110 stories you don't hear on a conservative side. To really understand the scale of this issue, let's look at the numbers.
t of network reimbursement in:
So in other words, Multiplan is touching over 80% of all out of network claims in the United States. But the problem isn't just the volume, it's the financial incentives.
For example, in one case highlighted by the New York Times, Cigna earned nearly $4.5 million in fees for processing claims from eight addiction centers in California. Those centers, they just received 2.5 million. Meanwhile, MultiPlan pocketed an additional $1.2 million. Think about that.
The combined fees for the insurer and Multiplan exceeded what the actual healthcare provider earned for treating patients. So what's the broader takeaway here?
First, this system flies in the face of value based care, which is supposed to align incentives around improving patient outcomes and reducing costs. Instead, we're seeing a model where insurers and third party companies profit by suppressing payments to providers and shifting costs onto patients.
Second, this is a transparency issue. Patients deserve to know how their bills are calculated, why their claims are being reduced, and where their money is going.
I mean, ultimately the patient ends up with a balanced bill, right? Finally, there is a role here for policymakers, employers and industry leaders to push for change.
I mean, we're signing these contracts whether it's new regulations or antitrust investigations which just lawsuit brings forth or renegotiated contracts. At your organizational level, there is a growing demand for accountability.
It's supposed to be a system that works for everyone, patients, providers and health insurance companies alike.
But stories like Kelsey Tony's and Gail Lawson's remind us that there's still a lot of work to do and I thank you for joining me on this journey today. If you find this episode eye opening, I encourage you to share with your network. Let's get the conversation going.
I will put up additional material on the multi plan lawsuit because I think it's so interesting and well written, but I'm going to do it in bite sized chunks. You can find the links to the New York Times investigation and other resources in the show notes and as always, I'd love to hear your thoughts.
Reach out to me on social media or any way you like. Until next time, I am Alex Aridjanian reminding you that real value in healthcare comes from putting people first.
Stay informed, stay engaged, and let's keep building a system together.
