MutiPlan Paying Contracted Rates on a Contract That Doesn't Exist

[acjlegal]

My question involves insurance law for the state of: CA

I have a Dr. Office and Surgery Center that is non-par with United Health and HealthNet.
They are using MultiPlan as a third party administrator for price reduction. They have been reducing my client’s bills on a contractual rate, but there has never been a contract. We requested a copy of the contract and I called MultiPlan and there excuse is that, "there system shows an UP & UP contract and although the contract cannot be produced, our records verify our participation."

We also inquired on the passed claims that were processed a few years prior at a reduced rate. Their response was "Client are limited to a timeframe for reprocessing and as we were not aware of the disputed claims within those timeframes any claims over 365 days cannot be reprocessed. The majority of the claims submitted were 2-3 years old."

The letter then closed with, "We must insist that all related claims be accepted based on the terms of your agreement and that patients are not billed for any amounts shown on the payors remittance advice that are related to PHCS/MulitPlan."

Oh PS. They also terminated the contract as of 11/05/2008, per our request. We never had a contract that is why we asked them to terminate.

Again there is not contract nor are we the client. I would appreciate any assistance. AJ

[cbg]

Maybe I just haven't had enough coffee yet today but after reading your post three times I still do not have the faintest idea what your question is.

[lealea1005]

Unless I'm also missing something....

Are you saying that UHC and HealthNet is now using PHCS/MultiPlan as their 3rd party a administrator?!? Oy, can they make it any more confusing??

What insurance company hold the patient's plan?

If your client is not contracted with the insurance plan, they do not have to accept the plan's "reasonable and customary" amount as payment in full, and can bill the patient the balance.

Is that the info you were looking for?

ETA: For what it's worth....MultiPlan tried the "you have a contract" on us a few months ago. They also could not produce the contract (that never existed) but insisted we were in their data base. They attempted to convince me we "automatically" signed with them when we renewed PHCS. I immediately faxed them a "withdrawal" from their plan, demanded to be taken off their provider list (that we shouldn't be on since we are non-par), and sent the info to the state Insurance Commission.

[momm2500]

wow! up and up/pro america was bought by multiplan some time ago. you will need to go that far back to find out what happened with the existing contracts that all providers and hospitals had with the merger. there might be a clause in there and notices that were sent to providers and hospitals back with the merger that indicates their original contract is being held in place. it is only a couple of years ago that PHCS(private health care systems) and multiplan merged.