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

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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.

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