The Chicago-based American Medical Association and the Illinois State Medical Society have sued data analysis company MultiPlan, alleging it is at the center of a price-fixing conspiracy with health insurance companies that has harmed medical practices and, by extension, patients.
The AMA and the state medical community allege in their lawsuit that most of the nation's health insurers outsourced to MultiPlan the task of determining how much they should reimburse doctors and other providers who provide services to out-of-network patients.
Typically, health insurance plans have groups of doctors and other providers who are considered “in-network” and with whom they have negotiated reduced reimbursement rates, in exchange for encouraging their patients to see them. But insurance companies also often reimburse “out-of-network” doctors, with whom they have not negotiated contracts, when they see insurance company members, based on those members' plans.
The AMA and the state medical community claim that this outsourcing has eliminated competition among insurers for out-of-network providers' services, resulting in artificially low reimbursement rates for out-of-network providers.
“Physicians are forced to accept increasingly low payment amounts for out-of-network services, which often do not even cover operating costs,” the organizations allege in the lawsuit, which was filed in the U.S. District Court for the Northern District of Illinois. Thursday.
The situation could also indirectly suppress in-network reimbursement rates, because doctors who receive lower out-of-network rates have less leverage to negotiate in-network reimbursement rates with health insurers, the lawsuit alleges.
“These dynamics have forced many practices, especially smaller ones, to close their doors, stop providing certain services, or join large hospital conglomerates, leaving patients with fewer and fewer health care options,” the AMA and state medical community allege in the lawsuit. .
Attempts to reach MultiPlan for comment were not immediately successful Thursday afternoon. On its website, while describing its services, MulitPlan says: “We identify and negotiate fair reimbursements for out-of-network providers and help eliminate balance bills.”
“Our role goes beyond just saving dollars and cents – everything we do supports the long-term goal of enabling affordable care for all,” MulitPlan says on its website.
MultiPlan faces a number of other similar lawsuits.
A New York Times investigation earlier this year found that MultiPlan and its insurers had a “substantial and often hidden financial incentive to reduce those reimbursements as much as possible,” sometimes resulting in large bills for patients and lower wages for providers.
The AMA and the state medical community are seeking “injunctive and other appropriate relief to put an end to the cartel and the injuries it inflicts on AMA and ISMS members and on health care throughout the United States,” according to the lawsuit.
Originally Posted: October 24, 2024 at 4:27 p.m
