Third-Party pricing Company Multi-Million Dollar Scheme: Inside the Out-of-Network Revenue Rush

Dear Reader,

A recent New York Times investigation has shed light on a troubling reality within the American healthcare system. The report reveals a complex web of financial incentives that drive some of the nation's largest health insurers to prioritize their own revenues at the expense of employers and patients. Source: The New York Times. 

The investigation uncovers the critical role played by data analytics firms such as MultiPlan, Data Insight, and Zelis in advising insurers like UnitedHealthcare, Cigna, and Aetna on the amounts to be paid for out-of-network claims. These amounts often fall significantly below the billed amounts or the patient's reimbursement rates, allowing insurers to charge employers a fee based on the "savings" accrued. While this model generates over $1 billion annually for UnitedHealth alone, it places an undue burden on patients and providers, who are left with low reimbursements and hefty bills.

MultiPlan's defense, arguing that it plays a crucial role in mitigating costly negotiations with healthcare providers, rings hollow due to the financial incentives that drive these third-party pricing companies to underpay providers. For every underpayment, a percentage of the difference is paid to the pricing company, creating a clear motive to exploit patients and providers.

The justifications offered by UnitedHealthcare, Cigna, and Aetna, citing efforts to control spiraling healthcare costs attributed to "egregious" provider charges, fail to address the fundamental injustice of this system. The American Hospital Association's forceful response, demanding a thorough investigation by the Department of Labor into potential violations of ERISA guidelines, underscores the gravity of the situation.

The current regulatory landscape, with only one Department of Labor investigator for every 8,800 health plans, is woefully inadequate to ensure fair practices and protect the rights of patients and providers. Most remain unaware of their rights or the correct recourse when faced with insurance underpayments and disputes.

This exposé serves as a clarion call for immediate action. It highlights the urgent need for regulatory scrutiny and reform to prevent undue financial burdens on patients and to align healthcare insurance practices more closely with the needs and rights of those they serve. The systematic underpayment to providers and corresponding overcharging of employers and patients by major health insurers through third-party pricing companies is a pervasive issue that demands our attention and action.



As a society, we must strive for a healthcare system that prioritizes patient well-being and fair treatment above profit margins. The time has come for a reevaluation of healthcare insurance practices and a commitment to transparency, accountability, and justice for all.

For more information contact visit our website @ www.compassmedicalbilling.com