Imagine this: You send a bill for your services, and the payer pays only two-thirds of the sticker price, without warning. That’s what’s happening to a number of psychologists and therapists.
“They’re stealing from me,” said a Manhattan Ph.D psychologist who spoke on condition of anonymity, describing the surprise underpayments for his services.
He said he is out of network with every insurer, and has been since about 15 years ago. He started to notice several years ago that after he filed a claim with Cigna, he would get a response from Cigna with a lower rate, and then in small print a mention of a company named “Data iSight,” citing an “allowed amount offered.”
“They’re not telling the patient or me,” he said — just sending a reimbursement that is “about 30 percent less than the bill.”
The front of the explanation of benefits is seemingly standard, except the rate has been cut, he said. “On the back, there’s this little sentence that says, ‘Provider. This is the Data iSight allowed amount offered. Direct inquiries to 877-489-5984. Members, you may owe more if offer is not accepted,” he said. “There’s no warning. There’s no asking. They just do the ‘negotiating’ for you.”
In one bill, all 12 of the charges for $300, which is considered reasonable for Manhattan, where he practices, were bumped down to $208.86. The bill had a column marked “Not covered/Cost reduction” for $91.14, totaling $1,093.68 for the 12 appointments, while he was paid $2,506.32 instead of the expected $3,600.
Two others billed at the same $300 were bumped to $199.68.
“I found that if I call that number, and I tell them we did not authorize this — we don’t negotiate. We’d like it reprocessed,” he said, the bill will be reprocessed and the additional money sent at some later date.
Cigna did not respond to several requests for comment.
‘Stupid call every month’
To be sure, this is not the only problem a clinician has had with an insurer. We wrote recently about how UnitedHealthcare’s Optum wing has told an untold number of clinicians that their mental health payments will be delayed for a “pre-payment review” that involves reams of paperwork, bringing outrage (and causing patients to stop treatment because they are not getting reimbursed.) And ProPublica recently wrote about how many therapists have decided they are not going to accept insurance, because of such practices.
But in this case, in the context of the widely acknowledged mental health crisis in the nation, another roadblock for treatments seemed worthy of note. Also, the psychologist was passionate about the issue. “The problem is, I have to make that stupid call every month,” he said in a Zoom interview. “I’ve called both Data iSight and Cigna and said, ‘We don’t want this anymore. We’re not interested in negotiating. I need it to stop.’ But you can’t make it stop. They just keep coming.”
All three patients, he said, are people for whom he accepts the copay and, as a courtesy, files for reimbursement for the remainder with the Cigna. In all three cases, he has to call every month to get the proper reimbursement.
“I would assume A. that it’s illegal, but it’s certainly unethical,” he said. “There is no mention of this. There is no discussion with the patient.” He said most patients and clinicians have no idea this is going on. “Because, you know, in a busy life, how many people actually read through their E.O.B.? We’re all used to insurance bumping things down a little bit.”
Further, he said people don’t know that there is a remedy — “even if it is a pain in the butt” — calling to insist on a reprocessing. He has never seen this with another company, only Cigna. When he calls, he said, the representative will “read the exact same script every time, and it’s something like we came up with that number based on blah, blah blah CPT code in your neighborhood.”
“It’s just a colossal waste of people’s time. I’m sure their business model is A, lot of people a won’t know and B, they’ll just get so tired of it that they’ll say, all right, 50 bucks here, 100 bucks here, why bother? And they will make a significant amount of money.”
And he chose not to take part in insurance plans because of the difficulties he encountered.
Update, Sept. 30: Lynne Spevack, a licensed clinical social worker who is a psychotherapist and practice building consultant in Manhattan and Brooklyn, wrote after reading this post: “One thought regarding your story about DataIsight and other repricing companies: these aggressive practices are discouraging clinicians from accepting assignment, which some have wanted to do to ease the financial burden on clients. Some colleagues who had been accepting assignment are deciding not to do this, based on these shenanigans. It’s another insidious way that the insurance industry makes it harder for people to use their insurance benefits.” Then, instead of accepting assignment as judged by the insurer, to be paid later, the clinician will ask the client to pay in full — a further burden on the client.
‘Billions of dollars’
This is not a new problem, but the Manhattan psychologist wanted to talk about how surreptitious it is — and how damaging. And it’s affecting many practices — not just therapists but doctors and medical professionals in other disciplines, as others have reported.
“A tool backed by private equity is helping insurers make billions of dollars and shift costs to patients,” Chris Hamby wrote over at The New York Times in April. “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.
“A New York Times investigation of insurers’ relationship with MultiPlan found that … 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.”
Out-of-network bills are frequently routed to MultiPlan for payments, he writes, and MultiPlan makes a recommendation. “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. This business model has made Data iSight a cash cow….
“For Mary Lavigne, who has chronic pain, chiropractor appointments near Irvine, Calif., almost doubled in cost. Nadia Salim’s Boston-area therapy appointments also became almost twice as expensive. And Andrew Faehnle was on the hook for more than two-thirds of an ambulance bill after his 14-year-old was rushed to an emergency room in Anaheim, Calif. In each case, insurance statements cited Data iSight.”
‘Eligible for repricing’
Barbara Griswold, author of the blog “Navigating the Insurance Maze,” and the book of the same name, is a therapist who helps other therapists with various aspects of the business of a practice, especially insurance. She wrote about Data iSight and similar intermediaries in February 2023.
“Let’s follow one story: Thelma Therapist had been billing a client’s plan $225 for each session. For months, the health plan allowed $200 per session. However, without warning, claims for three clients were paid with an allowed amount of $104 — almost half of what the plan had previously determined was reasonable.
“When Thelma calls the plan, she is told that these claims were referred to Data iSight, a subsidiary of Multiplan. She calls Data iSight, whose rep explains that claims from out-of-network providers are eligible for ‘repricing.”’ They are vague about the basis of their repricing — something about zip code averages. When Thelma declines to accept this reduced fee, they offer to negotiate, but she declines their offers. The Data iSight rep then assigns a case #, saying claims will be returned to the plan for re-evaluation. For one client, the plan adjusts the claim, and pays at the previous rate. Another claim is still awaiting reconsideration. …
“One can only imagine the uncomfortable situation this put Thelma in with her client. Thelma knew if she didn’t fight it, she would have to ‘balance-bill’ the client for any amount that the plan didn’t pay. That is, since Thelma had already submitted a claim charging $225 per session, she would normally need to collect that $225 total for each session. This would mean a huge surprise bill for the client, and significantly higher fees going forward, possibly forcing a client to end treatment. All of this is especially shocking in this era where we must give Good Faith Estimates to protect our clients from getting surprise bills. However, in some situations, therapists were told that they COULD NOT charge the client for the unpaid portion.”
Many lawsuits
Griswold wrote: “A quick online search will reveal that there are many lawsuits against CIGNA and UHC regarding these Multiplan underpayments, by a Northern California Intensive Outpatient Program, the American Medical Association, the Medical Society of New Jersey, The Washington State Medical Association, the Association of New Jersey Chiropractors, and the New York Emergency Physicians.”
The Manhattan psychologist said his claims were with Cigna, while Griswold wrote that she had heard also of claims from Aetna, Kaiser, Horizon, and United Health Care/Optum. She also wrote that Data iSight is not the only company with similar practices; a company called Zelis does it too. Other names that come up: Viant and Three Rivers, as well as others.
Secure Health, which uses Data iSight, says on its site: “For facility claims, Data iSight uses a patented methodology and publicly available data to recommend reductions from a cost-up rather than charge down approach. Using similar methods, practitioner claims are reduced based on median reimbursement levels. These methods are defensible, repeatable and completely transparent. In fact, Data iSight has a website, dataisight.com, that shows exactly how payment recommendations were made. This helps ensure that the medical providers not only have all the information they need to understand how their payment was
determined, but also that they can see that the reductions are fair.”
What you can do
Griswold writes:
“What can I do to prevent this from happening, or to keep this from happening going forward?
“Collect in full from the client up front. It is the best way to fully protect yourself financially. If the client has out-of-network benefits, give them a superbill to submit to their health plan. Or, if you want to continue to do courtesy billing for the client (after you have been paid in full for the session), on the CMS-1500 claim form, leave Box 13 blank, since this box authorizes payment to the provider; in Box 27 indicate ‘no’ that you do not accept assignment (payment), and in Box 29 put total amount client paid. Box 29 should equal the total amount billed in box 28.”
If the claim has been paid at a reduced rate, she wrote, you can ask for reprocessing. “Tell them you never agreed to a lower rate. They may offer to negotiate a special rate for you. You may want to ask for the offer in writing via email, and when you get it, reject it via email, so you have a paper trail of your rejection. At this point ask them to create a case number, and to send the claims back for reprocessing to the health plan telling the plan you have rejected the Data iSight offer.”
If you accept one negotiated rate, that may imply that you will accept others, she adds.
She also wrote that a therapist might suggest that the client talk to their Human Resources department, and ask them to make an appeal for the full payment.
Another path: She wrote that people could complain to the state insurance commissioner, Department of Insurance or professional association.
Do you have something we need to know about insurer payments or anything else noteworthy in healthcare? Email jeanne@clearhealthcosts.com or phone our secure Signal at 914-450-9499.
