November Newsletter

In this edition of the Mori West Seminars Monthly Newsletter we uncover companies like Zelis, EverCore, and MultiPlan; who they are and what they do. We go over the steps YOU need to make if you want to grow your practice. And in our Member's Only Article we go over why you shouldn't accept credit card payments from carriers and what you should do instead.

Enjoy!

-Mori West

If you’ve received letters, audits, or “re-priced” claims from any of these companies, you’re not alone. These third-party entities all play behind-the-scenes roles for major insurance carriers — and their goals are rarely aligned with providers or healthcare outcomes for that matter.

Here’s a quick breakdown of who they are and what they do:

Evicore

A “medical benefits management” company and subsidiary of Cigna.

Evicore handles prior authorization requests for carriers such as UHC, Aetna, Cigna, and various BCBS plans. They manage utilization review and determine whether care is “medically necessary.”

Cotiviti

An analytics firm that audits claims for accuracy, improper payments, and risk.

Many acupuncturists have been contacted by Cotiviti for risk-adjustment audits involving Medicare Advantage, Medicaid, and ACA plans. These aren’t documentation audits — they’re used to confirm that carriers are being paid correctly by the federal government.

WholeHealth Living

Builds “holistic networks” for health plans that may not already offer acupuncture, chiropractic, or massage benefits.

They also run a discount program, where participating providers agree to reduced service fees in exchange for potential patient volume.

Zelis

A third-party company working to create and supplement provider networks — often using proprietary re-pricing systems to lower claim payments. Their stated goal is to “help patients,” but the real effect is reducing reimbursement to providers.

MultiPlan

Known for offering reduced reimbursement to out-of-network providers.

Their business model is based on how much money they can save insurance carriers — not on fair provider compensation.

Data iSight

Owned by MultiPlan. Uses algorithms to determine a “recommended” payment — typically lower than previous reasonable and customary rates.

What’s the Common Thread?

All of these entities exist to increase revenue for insurance carriers — and reduce payments to providers.

What Can You Do?

• Never accept an “expedited reduction.”
• These offers often promise faster payment (within 10 days or less) but are never in your favor. Decline them.
• Always appeal reduced fee arrangements.
• As an out-of-network provider, you are not required to accept payment reductions. Make it a habit to appeal every time.
• Stay informed and connected.
• You’re not alone. A sweeping federal antitrust case is currently underway against MultiPlan. In April, the Department of Justice filed a Statement of Interest supporting that these practices may violate antitrust laws.

Many providers say they want to grow their practice — but few actually have a plan in place to make that happen.

Or maybe you don’t want more patients, but rather better patients — the kind who:

• Keep their appointments
• Don’t question your fees
• Actively promote you and your practice

Before you can grow, you have to know where you are now.

I often ask providers, “How many patients do you see each month?” Surprisingly, very few can give me a clear answer. The truth is: you get what you focus on. If you’re not paying attention, it shows up in your results.

Here are three key areas to start tracking and improving:

1. No-Show Rates – Track them weekly and monthly, and identify which patients are most consistent.
2. Administrative Tasks – Are claims submitted daily? Are notes completed within 24 hours?
3. Your Fees – When was the last time you reviewed them? If you’re charging the same rates as five years ago, you’re losing money. And if your cash rate is “one-size-fits-all,” you might be working for free in some cases.

So what should you do?

1. Get a benchmark. Document where you are today and set measurable goals for the future. Write them down and schedule regular reviews.
2. Create actionable steps. Break each goal into smaller tasks with deadlines. Build them into your daily routines — for example, “No lights off until notes are finished and claims are submitted.”
3. Track your progress. Set a recurring “check-in” date with yourself to review your progress.
4. Communicate with your team. Whether it’s your front office, associate, billing company, or bookkeeper — they all need regular check-ins, clear goals, and accountability.
5. Engage your patients. Help them set their own healthcare goals and celebrate their wins along the way.

Growth doesn’t happen by accident — it’s planned, tracked, and celebrated. Start today by choosing one area to focus on and build from there.

If you’ve recently received a “payment” from an insurance carrier like Vpay, Zelis, or QuicRemit, only to find it’s a Virtual Credit Card (VCC) — you’re not alone.

More and more carriers are using VCCs for provider payments, and if you process them, you’ll lose 3–5% in transaction fees. That money comes directly out of your...