乌鸦传媒

Welcome to the latest edition of Investigative Roundup, highlighting some of the best investigative reporting on healthcare each week.

Unraveling the MultiPlan Mystery

The little-known data analytics firm MultiPlan works with insurers to cut reimbursements to out-of-network providers, often leaving patients with large medical bills, according to a investigation.

Americans commonly get health insurance through self-funded plans from their employers, who contract with insurers to manage plans and process claims. While most medical visits are covered by predetermined rates with in-network providers, insurers consult with MultiPlan to negotiate payments with out-of-network providers.

MultiPlan frequently recommended that employers pay much less than what providers billed, and that was presented as a savings to the employer, the investigation found. However, those lower payments were accompanied by processing fees paid by the employer to the insurers and MultiPlan, which sometimes "far exceeded the amount paid to providers who treated the patient," the Times reported.

MultiPlan has reportedly worked with more than 100,000 health plans covering more than 60 million people, generating almost all of its revenue from those "savings"-based fees. MultiPlan and insurers claim they are fighting "rampant overbilling" by doctors and hospitals, the article stated.

In response to the Times' investigation, the American Hospital Association (AHA) to "immediately open an investigation" into these "unconscionable practices."

HCA Bulks Up Charity Care Spending in CMS Reporting

HCA Healthcare told CMS it provided nearly $1 billion more in financial assistance to patients than it reported on its 2022 financial statement, according to .

That allowed the hospital chain to extract billions of dollars from taxpayer-funded programs, STAT reported.

While discrepancies in charity care spending between CMS filings and annual financial statements are common, HCA's gulf is much wider than that of its for-profit and nonprofit rivals, the investigation found. For instance, the company with the next-highest charitable care spending reported to CMS, Tenet Healthcare, told the agency it spent $281 million more than was reported on its financial statement.

Charity care reported by hospitals to CMS plays a major role in determining where billions in federal and state supplemental payments to hospitals should go. In 2020, more than $80 billion in taxpayer money was distributed under this CMS rule, which was designed to offset losses for treating patients who rely on lower paying government assistance.

In 2022, HCA Healthcare brought in $3.9 billion from this rule, mostly from Medicare and state Medicaid programs, which do not consider how profitable a hospital has been, the report stated.

An HCA spokesperson told STAT the financial statement only contains charity care, while the CMS filing also includes uninsured discounts to patients who weren't eligible for charity care.

This tactic appears to be allowed under current CMS rules, but experts argue that it shouldn't count as charity care. Gerard Anderson, PhD, a health policy professor at Johns Hopkins University in Baltimore, told STAT that the numbers may not be fraudulent, but they are "suspicious."

FDA Panel's Industry Ties

Several members of an FDA advisory panel evaluating a cardiac device made by Abbott had financial ties to the company, which the agency failed to disclose, according to .

Ten of the 14 voting members on the panel evaluating the TriClip G4 System garnered about $650,000 from Abbott from 2016 through 2022, the most recent year for which data are available, according to the report. One panelist received almost $200,000 from Abbott, while another received roughly $100,000 in payments and an additional $50,000 in research support. A third member received more than $180,000 in research support from the company.

Financial conflicts of interest among panelists show the reach of industry money into the FDA approval process, and the limits of transparency at the agency, according to the report. An FDA spokesperson told KFF Health News that the agency "followed all appropriate procedures and regulations in vetting these panel members and stands firmly by the integrity of the disclosure and vetting processes in place." An Abbott spokesperson said the company had "no influence over who is selected to participate in FDA advisory committees."

Ultimately, the panel voted 13-to-1 in support of FDA approval of the device, which the agency approved earlier this month.

Comment