Oct 28, 2019

Private equity's other stake in surprise medical bills

Private equity firms don't just own physician firms and air ambulances that would be most affected by eradicating surprise bills. They also hold stakes in the companies that help health insurers determine what they should pay for out-of-network care.

Why it matters: Private equity has its footprint all throughout health care, but these financial firms especially have a lot on the line in Congress.

By the numbers: Seven major companies — CareCentrix, MedRisk, MultiPlan, naviHealth, One Call, Paradigm and Zelis — are hired by insurers to handle "health care cost containment," which includes things like bill editing and renegotiating out-of-network claims, according to Moody's Investors Service. 

  • Private equity owns a slice of each, and Moody's anticipates the aggregate annual revenue of these companies will reach $8 billion by 2020.
  • Two of those companies, MultiPlan and Zelis, are most directly involved with out-of-network claims and have the most to lose from any changes.

The big picture: Everything hinges on Congress' leading solution, which would use a benchmark rate to pay out-of-network providers.

  • "Should the new legislation set benchmark pricing, repricing claims would become de facto irrelevant, making part of these companies' business models obsolete," Moody's analysts wrote.

Yes, but: Because some of these companies already handle medical bill negotiating between providers and insurers, they "could play an active role in setting benchmark pricing for the industry and could even monetize their expertise," Moody's wrote.

  • "This would lessen the adverse impact of new legislation."

Go deeper: Private equity maximized profits while sick children were neglected

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