ques re:3rd party repricer Multiplan and Data ISight tactic

[ctk668]

Hi everyone,

I have a question regarding a tactic by a third party repricer (multiplan) that i have never seen before

I am a physical therapist who is out of network with Aetna. Usually Aetna will send claims to a 3rd party repricer (multiplan) and ive always ignored the negotiated rate offers from Multiplan because a higher reimbursement would always come if i was willing to wait it out and let it go back to Aetna. But recently on a few claims Multiplan is saying that if i dont accept their negotiated rate they will send it to another party called Data Isight and i would have to take a lower rate derived using their "geographic statistical data" or "regional price table" or something along those lines.

I have never seen this tactic before. I thought it might have been a scare tactic used by multiplan but it looks like they do this for real based on the only other post online that i could find about this topic seen in the post here: https://www.medicalbillinglive.com/members/index.php?topic=8824.0

So im not sure if i should take the negotiated rate or let it go to data isight and fight it out in the seemingly nightmarish appeals process.

My question to you all is:
1) Have any of you seen this tactic by Multiplan/Data Isight before? and if so, how to do you deal with it?

2) Does it make more sense to accept negotiated rate in these situations or do you let it go to Data Isight?

3.) and If you let it go to Data Isight how to do handle the appeals process and whats involved? Have you had any success with appealing and trying to get it sent back to the payor?

I would appreciate any insight you have about this situation. Thank you all

[Michele]

Personally this is a pet peeve of mine.  This makes me crazy.  They send it to a third party to "negotiate" a lower rate in exchange for a quicker payment.  But what they fail to mention is that in most cases they don't actually pay.  Because if you are out of network then the patient usually has a high deductible so you are simply agreeing to a lower amount for nothing. That may be different for PT since you are billing usually for 2-3 visits per week for several weeks, but for most providers it means $0 is paid.  THe patient ends up owning the whole amount.  So if you want to give your patient a discount that's fine, but don't give these third party companies a cut for 'negotiating'. 

We always tell them "we don't negotiate".

I haven't dealt with Data Isight directly but in looking at them on the website they look similar to Multiplan.

[PMRNC]

Michele is correct.. you do NOT have to negotiate. I will advise though that if you don't collect on the front end it's harder to collect from the patient refusing a negotiated rate. If any of these patient's are ERISA you can appeal the rates assuming you use the proper ARF which is much more extensive than an AOB.

[eastonthewestside]

I too have recently discovered my out-of-network payments have been processed by DATA ISIGHT at significant discount of my previously paid claims from the same insurance company (Aetna) and the same plans from 2018. On the Data Isight website they provide an explanation of a rate arrived at a percentage of the Medicare rate, but this is certainly not adjusted for the local area (NYC) usual and customary charges. I am not sure how to dispute this, but have been urged to send a spreadsheet of processed claims and my preferred rate to DI, which I will do, but I assume I will get the runaround.  I would like to complain to ERISA, but don't know how.  If anyone can advise, that might be helpful. 
Thank you-

[tcgiordano]

eastonthewestside should know that Aetna is falling in line with Cigna by processing insurance claims thru "third party repricing" mechanisms, and no longer in accordance with Federal And New York State Laws.
The methodology used is based on cost-containment and not the "usual, customary, and reasonable' in defiance of State And for Erisa-goverened Plans, Federal law.
This resulting in significant reduction in payment or nonpayment for services rendered its insureds!

This is not only unfair but also a breach of fiduciary obligations for their Plan beneficiaries, and by way of assignment of fees to the Providers. This behavior is also consistent with Rico violations, "predicated acts" ongoing in furtherance of reduced payment, False payment, and delayed payment!

in November 2018 a significant ruling for all planned sponsors, insureds and medical providers, the 7th Circuit Court of Appeals ruled Plans must provide third-party pricing documents and methodologies relied on to determine 'usual, customary, and reasonable' rates.

There exist in contract btw Plan Administrators (Cigna, Aetna) and its insured beneficiaries an implied covenant of 'Good Faith' and fair dealings. Any dealings with 'Third party administrators',
(data iSight/Multiplan) has been anything but fair for out-of-network providers.

Eastonthewestside should know they are entited to assert a claim for relief against the Plan sponsors or payors, in this case Aetna directly in State Supreme Court, pursuant to various sections of ERISA, where State Supreme Court has jurisdiction over this subject mater.

[ptino.jfpt]

We are out-of-network PT provider in Manhattan

If Data Isight has a failed negotiation with the provider (provider refused to accept the repriced/discounted claim), Cigna will reprocess claim based on their member's plan benefit. This takes time but at least we get paid properly.

Aetna - only started with Data Isight this year. Also, Aetna created a National Advantage program (NAP) seen in almost all Aetna ID card. NAP triggers OoNet claims to be sent to Data Isight for repricing. I managed to disconnect our Tax ID to that program and our claims were reprocessed accordingly but that didn't last long. As of May, our claims are being sent to DI again and according to some Aetna claims supervisors, I was given the wrong information.

My office is looking for legal advice on how to dispute DI discount at this time. We can all help each other!

[Michele]

Sorry but I can't help with legal advice.  I know it's frustrating though.  I hate these middle men.

[margarita0930]

From my experience, you can negotiate reimbursement for OON PT claims with DataIsight.  For example: Aetna/Cigna. Billed amount $1,350/$1100 for I/E and $880 for F/U- they automatically pay around $130/$150 per visit. When you call DataIsight you can open a case for negotiation and request 40% off of the billed amount. We in NYC usually get around $500-$380 per visit. Not sure what the OON reimbursement is in other states. Hope this info helps.

[Debw00]

Please -any help with fighting this Aetna /Data isight is needed.  Called a lawyer versed in these matters-she said its possible Aetna would retaliate against my practice.  This must be fought by an association or legally thru govt channels.   I don't understand why the New york Chiropractic Association or Counsel has not brought action yet.....

If anyone has any any info please advise

[Michele]

I'm sorry but we haven't had any dealings with them.  I'm not sure what to recommend.

[cflorez]

Based on these out of network problems in billing. I have a question for you all. Years ago out of network was the way to go, Many of my clients liked to be out of network. Not so sure any more. I do know that in my experience out of network providers in regards to appeals I get no help from the Insurance Carriers rep. Can any of you share if you believe,  in or out of network is best.

[kristin]

There is no easy answer to this question, as it depends on the mentality of each provider. Some don't want to  play the "insurance game" and choose to be OON, others want to get as many patients as they can, and contract with every insurance that they can. Here is what I have found over the years...most PATIENTS want to know that they are seeing a contracted provider with their insurance. And you have to be honest with them when they call, and ask if your office/provider is in network. If your provider isn't, you will lose patients, because they will say thanks, but no thanks, and move on to a provider who is is contracted with their plan.

Right now, I am dealing with contracting a provider with all insurances our office is contracted with. Unfortunately, there is one insurance in our area that is no longer accepting providers within our specialty. (Humana, Podiatry). So while two of the docs in our practice are grandfathered in with Humana, the newest one can't get into Humana(which is fine by me, I HATE Humana). So when a patient with Humana calls, we have to explain that while they can schedule with two of our providers, and that will be a few weeks for an appointment, they can also schedule with the new provider immediately, but it will be out of network. 9 times out of 10, the patient says they will call around for another appointment, that will be sooner, with an in-network provider. And I completely understand why. Who wants to see an OON provider when they can see one who is in-network?

There are situations where not being contracted doesn't matter to potential patients, and not being contracted doesn't matter to the provider. But they are not the norm. It depends on the provider specialty/financial situation/length of practice, and the patient demographic in your area.

[PMRNC]

Actually there are a couple of EASY solutions,  tell third party you don't negotiate like Michele says, those repricing companies are nothing more than a carrot dangling on a stick. The min you sign the "deal" you lose your ability to appeal so I don't understand why providers even take those deals to begin with.

For non ERISA and out of network, this is really easy. With ERISA the insured is entitled to certain details about how a claim was paid or not, an adverse benefit under ERISA is any denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit. That gives the beneficiary a chance to appeal the payment reduction and request ALL documents, certifications and names of all those who made the determination and details on how the benefit was reduced and why. A provider can do this on behalf of a patient but they need the proper ARF which gives the provider the right to act on behalf as a representative of the member/patient. A valid assignment of benefits is not sufficient so you will need the patient to sign an ARF. You'll also want their benefit plan (SPD) which details the appeal process which must be followed to a "T" in most cases you are NOT appealing to the carrier but possibly to an executive board, the employer or fiduciary, etc. When you put your appeal letter to work and it is received, MOST times the carrier will reverse the denial or increase the benefit payment (This type of appeal always works for me on U&C reductions) because they will fail to meet the appeal rights and grant the documentation the member is entitled to.

With Aetna you just have to watch your Medicare replacement plans, those are not ERISA but they also do not have to play by all the rules of Medicare.

Just FYI:  more than 85% of all claims the average biller touches, are ERISA. Knowing that up front, obtaining the proper ARF and benefit verification allows you to get ahead of situations like this.

[gesheva123]

Please -any help with fighting this Aetna /Data isight is needed.  Called a lawyer versed in these matters-she said its possible Aetna would retaliate against my practice.  This must be fought by an association or legally thru govt channels.   I don't understand why the New york Chiropractic Association or Counsel has not brought action yet.....

If anyone has any any info please advise

Hi Deb - interested in the topic. Did you find out if Aetna can retaliate? Does this still happen to you?

From what I have found so far, you are not obliged to accept a lower payment offered via Multiplan or Data iSight. Your benefit must be just getting your money faster (so useful for cash management) but you accept a lower amount. Alternatively, you can reject and receive your normal payment just it could take longer. So my understanding is that the benefit to physicians is just time (and well the cost associated with that).

Does the above sound right?

Thank you!

[gesheva123]

From my experience, you can negotiate reimbursement for OON PT claims with DataIsight.  For example: Aetna/Cigna. Billed amount $1,350/$1100 for I/E and $880 for F/U- they automatically pay around $130/$150 per visit. When you call DataIsight you can open a case for negotiation and request 40% off of the billed amount. We in NYC usually get around $500-$380 per visit. Not sure what the OON reimbursement is in other states. Hope this info helps.

Hi Margarita,

I am a little confused - are you a health service provider or a physician? I thought health providers would prefer or would like to negotiate for a higher reimbursement?! How does it make sense to negotiate a lower payment? Or are you speaking as a patient?

Thank you!