Health insurers have made an enticing pitch to local governments across the country: When your workers see doctors outside your health plan’s network, costs can balloon, but we offer a program to protect against outrageous bills.Cities, counties and school districts have signed up, hoping to control the costs of their medical benefits.Then come the fees.In Shelby County, Tenn., the insurer’s charges for administering the program climbed last year to $1.3 million — more than the county budgeted this year for long-term disability insurance for all of its roughly 6,000 employees.In Hoboken, N.J., the charges sometimes exceeded the amount paid to doctors for providing treatment. And in a stretch of California’s Central Valley where two counties share a health plan, the fees unexpectedly quintupled in one year to more than a quarter-million dollars, contributing to a plan deficit.MultiPlan, a data analytics firm, helps insurers reduce payments to doctors, then keeps a portion of the savings for itself.José A. Alvarado Jr. for The New York TimesFrom southern Florida to the Pacific Northwest, local governments have paid similar fees, often with little awareness that their taxpayer dollars have become a lucrative revenue stream for some of the nation’s largest insurers, according to a review of documents obtained in two dozen public records requests and interviews with city and county officials and benefits consultants.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Lawmakers are zeroing in on MultiPlan, a firm that has helped insurers cut payments while sometimes leaving patients with large bills.Lawmakers on Tuesday called on health insurance regulators to detail their efforts against “troubling practices” that have raised costs for patients and employers.In a letter to a top Labor Department official, two congressmen cited a New York Times investigation of MultiPlan, a data firm that works with insurance companies to recommend payments for medical care.The firm and the insurers can collect higher fees when payments to medical providers are lower, but patients can be stuck with large bills, the investigation found. At the same time, employers can be charged high fees — in some cases paying insurers and MultiPlan more for processing a claim than the doctor gets for treating the patient.The lawmakers, Representatives Bobby Scott of Virginia and Mark DeSaulnier of California, both Democrats in leadership positions on a House committee overseeing employer-based insurance, highlighted MultiPlan as an example of “opaque fee structures and alleged self-dealing” that drive up health care costs. In their letter, they pressed the department for details on its efforts to enforce rules meant to promote transparency and expose conflicts of interest.MultiPlan’s business model focuses on the most common way Americans get health coverage: through an employer that “self-funds,” meaning it pays medical claims with its own money and uses an insurance company to process claims. Insurers such as Aetna, Cigna and UnitedHealthcare have pitched MultiPlan’s services as a way to save money when an employee sees a provider out of network.In many cases, MultiPlan uses an algorithm-based tool to generate a recommended payment. Employers typically pay insurers and MultiPlan a percentage of what they call the “savings” — the difference between the recommendation and the original bill.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

MultiPlan has helped big health insurers make billions by reducing reimbursements for medical bills, but its business model is now being questioned.Already under investigation in Congress, a data analytics firm that has helped major health insurers make billions of dollars by reducing reimbursements for medical bills is facing growing scrutiny from Wall Street and in the courts.The firm, MultiPlan, and the insurance companies it serves often collect larger fees when payments to medical providers are far lower than the amount billed. A recent investigation by The New York Times found the approach left some patients with unexpectedly high bills as they were asked to pick up what their plans did not cover.MultiPlan has seen its stock price drop by more than 70 percent since April, when The Times published its investigation, and its general counsel and chief financial officer have left their jobs. It disclosed quarterly financial results this month that its chief executive called “disappointing and unacceptable,” and it warned of a future hit to revenues as well.The chief executive, Travis Dalton, acknowledged during a call with analysts that “media scrutiny has been an ongoing challenge.” The firm attributed slumping revenues largely to changes by major clients, though it declined to provide more detail.In a note to investors, the research firm CreditSights, which regularly follows the company, said it suspected some clients were responding to “increased scrutiny on MultiPlan’s business model” and had “gravitated away from using MultiPlan in light of The New York Times article.”Insurers who manage so-called self-funded health plans for employers — the most common way Americans get health coverage — often turn to MultiPlan for payment recommendations when patients receive care outside their plan’s network. The Times investigation found that MultiPlan had encouraged some insurers to use its most aggressive pricing tools, leaving medical providers with slashed compensation and employers with high fees — in some instances higher than the medical care payment itself.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

The Times wants to hear from patients and providers about medical practices affiliated with Optum, a subsidiary of UnitedHealth Group. Share your experience below.Health care in America is changing. The days of small, independent medical practices have mostly passed. Today, most doctors work for a large corporation. Acquisition sprees by hospitals, health systems, private equity firms and health insurers have given a relatively small number of companies outsize control over a $4.5 trillion industry with extraordinary consequences for people’s daily lives.Amid this wave of consolidation, one company stands apart. UnitedHealth Group, which owns the nation’s largest insurer, also employs or is affiliated with roughly 90,000 doctors — more than any other company. Through its lesser-known subsidiary Optum, it operates primary care practices, specialty clinics, home health agencies, urgent care centers and other facilities across the country.This combination is at the core of the company’s growth strategy and has led to record profits. The Times wants to understand what it has meant for Optum’s patients and medical professionals. We’d especially like to know about any changes that occur when Optum buys or contracts with a medical practice.Help The Times report on Optum.Step 1: Unsure whether Optum owns or contracts with your clinic? Click here to see a state-by-state list of Optum-affiliated practices. (Note: This list is not exhaustive.)Step 2: If you are a medical professional who has worked at an Optum-affiliated practice, if you are a patient at one, or if you have something else to share, please fill out the questionnaire below. (You’ll see provider questions first, then questions for patients.)Step 3: Share the link to this questionnaire within your networks so we can hear from more people.What happens when you share your story?A Times reporter may reach out to you to learn more about your story. We will not share your contact information outside the Times newsroom or use it for any reason other than to get in touch with you. And we will not publish any part of your response without verifying your information and hearing back from you. If you prefer to share your story anonymously, you can do so through our tips page.

A data analytics firm that helps insurers collect big fees while leaving some patients with unpaid bills has been summoned to explain its business model.The chairmen of two Senate committees overseeing health policy, concerned about companies “padding their own profits” at the expense of patients, are looking into the practices of a data analytics firm that works with big insurers to cut payments to medical providers.The firm, MultiPlan, recommends what it says are fair payments for medical care, but the firm and the insurers can collect higher fees when payouts are lower. This business model could “result in an improper conflict of interest,” the chairmen of the two committees, Ron Wyden of Oregon and Bernie Sanders of Vermont, wrote in a letter to the firm’s chief executive that was released on Tuesday.The senators called on MultiPlan to meet with the committees’ staffs to discuss an investigation last month by The New York Times that found the firm’s pricing tools could leave patients with unexpectedly large bills when they see doctors outside their health plans’ networks.“Our committees are engaged in ongoing legislative work to put a stop to practices by plan service providers that drive up health care costs for consumers while padding their own profits,” the letter to Travis Dalton, the MultiPlan chief executive, said.In a statement, MultiPlan said it was working with the Senate committees “to address their questions and explain the cost and complexity patients can face” when choosing high-priced care outside their networks. “We are committed to helping make health care transparent, fair and affordable for all,” the statement said.The committees’ inquiry reflects growing scrutiny of the New York-based firm, which has largely remained out of the limelight even as it has staked out a dominant position in a lucrative corner of health care.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

A data analytics firm has helped big health insurers cut payments to doctors, raising concerns about possible price fixing.Recent revelations about a data analytics firm’s role in determining medical payments have heightened concerns about possible price fixing in health care and led to a call for a federal investigation.In a letter this week, Senator Amy Klobuchar asked federal regulators to examine whether algorithms used by the firm, MultiPlan, have helped major health insurers conspire to cut payments to doctors and leave patients with large bills. She cited a New York Times investigation last month into MultiPlan’s dominance of the lucrative business of pricing out-of-network medical claims.“Algorithms should be used to make decisions more accurate, appropriate and efficient, not to allow competitors to collude to make health care more costly for patients,” Ms. Klobuchar wrote to the heads of the Justice Department’s antitrust division and the Federal Trade Commission.When patients see a medical provider outside their plan’s network, insurers often send their claims to MultiPlan, which uses proprietary algorithms to recommend how much to pay. By driving down payments to providers, MultiPlan and the insurers can collect higher fees for themselves, The Times reported, but this can lead to higher bills for patients, who may get charged the unpaid balance.UnitedHealthcare, Cigna, Aetna and other major insurers use MultiPlan’s pricing recommendations, and the firm has boasted to investors that it is “deeply embedded” in its clients’ claims-processing systems.In interviews, Ms. Klobuchar, a Democrat from Minnesota, and experts in antitrust law said this arrangement could amount to price fixing: Rather than competing to offer better coverage, insurers could use the low prices recommended by MultiPlan’s algorithms, knowing their competitors would likely do the same.“This should trigger an investigation by the agencies,” said Barak Orbach, a law professor at the University of Arizona. “There seems to be a really strong case.”The F.T.C. and Justice Department declined to comment, but both agencies have raised concerns in the past about similar arrangements in other industries.“Algorithms should be used to make decisions more accurate, appropriate and efficient, not to allow competitors to collude to make health care more costly for patients,” Senator Amy Klobuchar wrote in a letter to antitrust regulators.Valerie Plesch for The New York TimesMultiPlan did not have an immediate comment. But in legal filings, the firm has denied allegations of collusion and said that insurers are free to reject its pricing recommendations or negotiate higher payments with providers.The firm said in a previous statement to The Times that its work benefits patients and employers who pay for their workers’ coverage by “promoting affordability, efficiency and fairness across the U.S. health care system.”Insurers have said that MultiPlan’s tools help combat outrageous billing by some providers, including consolidated hospital systems and private-equity-backed staffing firms.Documents reviewed by The Times indicate that MultiPlan has sometimes told insurers how their unnamed competitors were using the firm’s pricing tools. In a 2017 presentation to UnitedHealthcare, MultiPlan shared “Recent Client Strategies to Improve Results,” which included techniques that could reduce payments to providers.After a 2019 meeting, a UnitedHealthcare senior vice president reported to her colleagues that a MultiPlan executive “did not specifically name competitors but from what he did say we were able to glean who was who.” She then described how Cigna, Aetna and some Blue Cross Blue Shield plans were apparently using the firm’s pricing tools.Three hospital systems have sued MultiPlan, accusing it of colluding with major insurers to set unreasonably low payments for medical care, and patients and providers have complained to the F.T.C. about MultiPlan, records obtained through a public records request show.One provider reported slashed payments from UnitedHealthcare, Cigna and an Aetna subsidiary after the insurers routed claims to MultiPlan’s most aggressive pricing tool. Another said the tool “has decimated my life” and caused “the closing of my business,” which has “left patients having to travel 2.5 hrs for surgery.”Patients complained to the agency of receiving large bills after insurers used MultiPlan-recommended prices. “This is now affecting my credit score,” wrote one patient, describing a bill that had been sent to a debt collector. Another reported being billed thousands of dollars “since they refuse to pay my providers the correct amount.”Pricing algorithms have driven MultiPlan’s growth over the past 15 years. The firm previously focused on controlling costs by negotiating with medical providers, but after being sold to private equity investors, it embraced automated, algorithm-based tools, which typically yield lower payment recommendations.Access to data from hundreds of clients has helped entrench the firm’s dominance, executives have told investors. “We build our algorithms on a much larger data lake,” one executive said in a 2020 presentation.The focus on MultiPlan’s automated pricing tools highlights growing concern among regulators and some in Congress that algorithms are supercharging price-fixing schemes and driving up costs for consumers.During the Biden administration, companies’ increasing embrace of technological advancements has collided with aggressive enforcement efforts by regulators. The results have been mixed, as the agencies seek to apply laws enacted to combat 19th-century oil and railroad robber barons to 21st-century technology firms.“Algorithms are the new frontier,” the Justice Department wrote in a brief in one case. “And, given the amount of information an algorithm can access and digest, this new frontier poses an even greater anticompetitive threat than the last.”Regulators and some antitrust scholars worry that algorithms can enable sophisticated collusion that is difficult to police. Competitors no longer need to meet in secret to hatch a conspiracy and communicate among themselves to perpetuate it. They can simply agree to use a common pricing algorithm.Weighing in on private lawsuits involving apartment rents and hotel room prices, the agencies have argued that such an arrangement is illegal, even if competitors agree with a wink and a nod rather than a formal pact.But in one case, a judge disagreed in a December ruling, allowing the lawsuit to go forward but requiring renters to offer more explicit evidence that landlords had conspired to raise prices using an algorithm.Ms. Klobuchar has introduced legislation that would effectively make the agencies’ position the default. Courts would presume it illegal for competitors to share nonpublic data with a middleman and use the pricing recommendations that the firm’s algorithms produced.“It is not clear whether current antitrust laws are sufficient to stop this practice,” Ms. Klobuchar said in an interview. “It is much better just to clarify this and to close the loophole.”The bill would also require companies to tell consumers if they are buying something that was priced using an algorithm, and it would give regulators greater authority to demand details about how an algorithm works.

Federal regulation capping toxic airborne silica has been decades in the making. The delay has cost miners dearly.Federal regulators on Tuesday will issue new protections for miners against a type of dust long known to cause deadly lung ailments — changes recommended by government researchers a half-century ago.Mining companies will have to limit concentrations of airborne silica, a mineral commonly found in rock that can be lethal when ground up and inhaled. The new requirements will affect more than 250,000 miners extracting coal, a variety of metals, and minerals used in products like cement and smartphones. Tuesday’s announcement is the culmination of a tortuous regulatory process that has spanned four presidential administrations.Miners have paid dearly for the delay. As progress on the rule stalled, government researchers documented with growing alarm a resurgence of severe black lung afflicting younger coal miners, and studies implicated poorly controlled silica as the likely cause.“It should shock the conscience to know that there’s people in this country that do incredibly hard work that we all benefit from that are already disabled before they reach the age of 40,” said Chris Williamson, head of the Mine Safety and Health Administration, which is issuing the rule. “We knew that the existing standard was not protective enough.”The new requirements are to be announced by Acting Secretary of Labor Julie Su at an event in Pennsylvania Tuesday morning. They come eight years after a sister agency, the Occupational Safety and Health Administration, issued similar protections for workers in other industries, such as construction, countertop manufacturing and fracking.Both mine safety advocates and industry groups generally support the rule’s central change: halving the allowed concentration of silica dust. But their views on the rule, proposed last July, diverge sharply over enforcement, with mining trade groups arguing that the requirements are unnecessarily broad and costly, and miners’ advocates cautioning that companies are largely left to police themselves.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

A private-equity-backed firm has helped drive down payments to medical providers, drive up patients’ bills and earn billions for insurers.Large health insurers are working with a little-known data company to boost their profits, often at the expense of patients and doctors, a New York Times investigation found. A private-equity-backed firm called MultiPlan has helped drive down payments to medical providers and drive up patients’ bills, while earning billions of dollars in fees for itself and insurers.To investigate this largely hidden facet of the health care industry, The Times interviewed more than 100 patients, doctors, billing specialists, health plan advisers and former MultiPlan employees, and reviewed more than 50,000 pages of documents, including confidential records made public by two federal judges after petitions from The Times.Here are five takeaways.The smaller the payout to doctors, the bigger the fees for insurers and MultiPlanWhen patients see medical providers outside their plans’ networks, UnitedHealthcare, Cigna, Aetna and other insurers often send the bills to MultiPlan to recommend a payment amount.MultiPlan and the insurers have a powerful incentive to keep the payments low because their fees get bigger as the payments get smaller.Here’s how it works.The most common way Americans get health coverage is through an employer that pays for workers’ medical care itself and uses an insurance company to administer the plan. Providers in the plan’s network have agreed-upon rates, but out-of-network providers often must negotiate payments.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

A little-known data firm helps health insurers make more when less of an out-of-network claim gets paid. Patients can be on the hook for the difference.Weeks after undergoing heart surgery, Gail Lawson found herself back in an operating room. Her incision wasn’t healing, and an infection was spreading.At a hospital in Ridgewood, N.J., Dr. Sidney Rabinowitz performed a complex, hourslong procedure to repair tissue and close the wound. While recuperating, Ms. Lawson phoned the doctor’s office in a panic. He returned the call himself and squeezed her in for an appointment the next day.“He was just so good with me, so patient, so kind,” she said.But the doctor was not in her insurance plan’s network of providers, leaving his bill open to negotiation by her insurer. Once back on her feet, Ms. Lawson received a letter from the insurer, UnitedHealthcare, advising that Dr. Rabinowitz would be paid $5,449.27 — a small fraction of what he had billed the insurance company. That left Ms. Lawson with a bill of more than $100,000.“I’m thinking to myself, ‘But this is why I had insurance,’” said Ms. Lawson, who is fighting UnitedHealthcare over the balance. “They take out, what, $300 or $400 a month? Well, why aren’t you people paying these bills?”Gail Lawson faced more than $100,000 in bills after a complex surgery. Her insurance paid out $5,449.27.Bryan Anselm for The New York Times

As medical practices owned by private equity firms fuel overbilling, a payment tool also backed by such investors helps insurers boost their profits.Insurance companies have long blamed private-equity-owned hospitals and physician groups for exorbitant billing that drives up health care costs. But a tool backed by private equity is helping insurers make billions of dollars and shift costs to patients.The tool, Data iSight, is the premier offering of a cost-containment firm called MultiPlan that has attracted round after round of private equity investment since positioning itself as a central player in the lucrative medical payments field. Today Hellman & Friedman, the California-based private equity giant, and the Saudi Arabian government’s sovereign wealth fund are among the firm’s largest investors.The evolution of Data iSight, which recommends how much of each medical bill should be paid, is an untold chapter in the story of private equity’s influence on American health care.A New York Times investigation of insurers’ relationship with MultiPlan found that countering predatory billing is just one aspect of the collaboration. Low payments have burdened patients with unexpectedly large bills, slashed pay for doctors and other medical professionals and left employers that fund health plans with high, often unanticipated fees — all while making the country’s biggest health insurance companies a lot of money.Often, when someone gets insurance through an employer and sees a doctor outside the plan’s network, the insurer routes the bill to MultiPlan to recommend an amount to pay. Both MultiPlan and the insurer receive processing fees from the employer, usually based on the size of the final payment: the smaller the payout, the bigger the fees.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.