Warning to Out-of-Network Therapists: Sudden Payment Reductions, and How to Avoid The Tricks of Data iSight, Multiplan, and Zelis
By Barbara Griswold, LMFT,
Originally published Feb 19, 2023; updated March 12, 2023 updates in red)
You could be next if you are kind enough to do “courtesy billing” for out-of-network clients — that is, if you submit claims on behalf of your client to the health plan, and once the health plan pays you, you collect the rest of your fee from the client.
Let’s follow one story: Thelma Therapist had been billing a client’s plan $225 for each session. For months, the health plan allowed $200 per session. However, without warning, claims for three clients were paid with an allowed amount of $104 — almost half of what the plan had previously determined was reasonable.
When Thelma calls the plan, she is told that these claims were referred to Data iSight, a subsidiary of Multiplan. She calls Data iSight, whose rep explains that claims from out-of-network providers are eligible for “repricing.” They are vague about the basis of their repricing — something about zip code averages. When Thelma declines to accept this reduced fee, they offer to negotiate, but she declines their offers. The Data iSight rep then assigns a case #, saying claims will be returned to the plan for re-evaluation. For one client, the plan adjusts the claim, and pays at the previous rate. Another claim is still awaiting reconsideration (due to the delay, Thelma also submitted a reconsideration request directly to the plan).
One can only imagine the uncomfortable situation this put Thelma in with her client. Thelma knew if she didn’t fight it, she would have to “balance-bill” the client for any amount that the plan didn’t pay. That is, since Thelma had already submitted a claim charging $225 per session, she would normally need to collect that $225 total for each session. This would mean a huge surprise bill for the client, and significantly higher fees going forward, possibly forcing a client to end treatment. All of this is especially shocking in this era where we must give Good Faith Estimates to protect our clients from getting surprise bills. However, in some situations, therapists were told that they COULD NOT charge the client for the unpaid portion.
What health plans are doing this, and where? While Thelma was billing CIGNA, I’ve heard the same story from therapists nationwide dealing with other plans, including Aetna, Kaiser, Horizon, and United Health Care/OPTUM.
Is Data iSight the only one doing these repricing? No. A company called Zelis is one of a number that is now providing the same repricing service.
And there are variations. Another therapist said her Aetna claim was outsourced to Meritain Health, who processed the claim at a sharply reduced rate (from the previous allowed amount of $195 to $91), and sent her a paper credit card payment. When she questioned Aetna, they told her to contact Data iSight. While Data iSight initially promised to discuss a negotiated price, in the end they refused, saying they felt their prices were fair.
Why did this happen? Some therapists have suggested that there may be some evidence that they were targeted because they answered “Yes” to “Accept Assignment” in Box 27 of the CMS-1500 claim form.
What can I do to prevent this from happening, or to keep this from happening going forward?
Collect in full from the client up front. It is the only way to fully protect yourself financially. If the client has out-of-network benefits, give them a superbill to submit to their health plan. Or, if you want to continue to do courtesy billing for the client (after you have been paid in full for the session), on the CMS-1500 claim form, leave Box 13 blank, which authorizes payment to the provider, in Box 27 indicate “no” that you do not accept assignment, and in Box 29 put total amount client paid. Box 29 should equal the total amount billed in box 28.
What if I’ve had a claim paid at a reduced rate, and I want to fight it?
Call the health plan (one provider told me she always asks for an onshore person, as she finds they have more power to make changes as needed). If they instruct you to call Data iSight or Zelis to negotiate, tell them no, you would like them to “pull back” the claims from Data iSight or Zelis and reprocess them at the normal rate. If they refuse, call Data iSight or Zelis. Tell them you never agreed to a lower rate. They may offer to negotiate a special rate for you. You may want to ask for the offer in writing via email, and when you get it, reject it via email, so you have a paper trail of your rejection. At this point ask them to create a case number, and to send the claims back for reprocessing to the health plan telling the plan you have rejected the Data iSight offer.
If you are tempted to accept a negotiated rate from Data iSight for one client, understand that this may have implications for other clients. Signing a discount-rate agreement will likely apply to your other clients from that health plan, or even others that have the words “Multiplan” on their insurance cards.
If you get stuck, you may want to suggest that the client contact their Human Resources or Benefits Management representative, to have this rep reach out to the health plan directly about this issue. Insurance plans are generally more responsive to employer complaints.
Any other tips? Whenever you contact an insurance plan, keep detailed notes, including recording dates of your calls, who you spoke with, their phone numbers and titles, what they said, and call reference numbers. You may need this information later. Plus, call reference numbers can help them find their notes and even recordings from your previous calls.
Is anyone fighting this? A quick online search will reveal that there are many lawsuits against CIGNA and UHC regarding these Multiplan underpayments, by a Northern California Intensive Outpatient Program, the American Medical Association, the Medical Society of New Jersey, The Washington State Medical Association, the Association of New Jersey Chiropractors, and the New York Emergency Physicians.
Also, Washington State therapist Ryne Evans is collecting information from therapists this has happened to, for a possible class-action lawsuit against these companies. At the time we spoke he had 15 therapists involved. If you are willing to share your experiences with him (with no obligation to participate in the case) he invites you to contact him here.
You may also want to reach out to your State Insurance Commissioner, your Department of Insurance, and your professional association to complain about this.
One final question: Are these the same as the Multiplan Negotiated Fee Agreements (NFAs) I’ve received? No, that’s another type of Multiplan monkey business. With NFAs, Multiplan reaches out to out-of-network therapists, even those that only give superbills, and asks them to accept a lower price for current or future claims. Their request is not clear, and therapists often don’t realize what they are signing. If you get a NFA, you should respond and refuse the offer. The difference between repricing and NPAs is that with a NFA, Multiplan is asking you first — they haven’t already messed with your payments.
Need advice about dealing with difficult or deceptive insurance plans? Contact me for a consultation — click here