Out-of-network pricing lawsuits test MultiPlan, Zelis business models

Antitrust lawsuits brought by healthcare providers against insurers and two of their contracted platforms are proceeding with high stakes, although the road to a final outcome will be long.

Billions of dollars and implications for the business models of insurers and pricing vendors are on the line in litigation against MultiPlan (now known as Claritev) and Zelis, along with their insurer clients.

In each case, plaintiff providers say insurers conspired with a pricing intermediary to underpay out-of-network claims by deploying repricing tools or algorithms. Both vendors are alleged to have served as a hub that coordinates prices among insurers that otherwise would compete with one another on price.

Claims of pricing suppression through repricing tools

The Zelis case is smaller in scale than the MultiPlan litigation and not as far along, although its status has been in the news more recently.

At the end of March, a judge with the U.S. District Court of Massachusetts denied a motion by Zelis and major insurers to dismiss the lawsuit, allowing the case to proceed to the discovery phase. Judge Brian Murphy (a Biden nominee) indicated provider plaintiffs, which consist of a half-dozen medical and dental practices, have plausibly made the case for a pricing conspiracy that violates Section 1 of the Sherman Act.

Among the allegations are that the vendor’s repricing tools suppressed payment rates for out-of-network care. Those tools included a proprietary fee schedule that the plaintiffs describe as being based on in-network rates and pooled from data across payers, along with a reference-based pricing methodology that’s derived from external benchmarks.

In the preliminary ruling, the court supported the plaintiffs’ contention that “Zelis’s repriced claims ‘are not mere proposals, recommendations or suggestions,’ [but are] essentially a ‘take-it-or-leave-it’ proposition for the provider.” Negotiations and appeals processes are “effectively nonexistent,” according to the plaintiffs, and Zelis receives a share of the savings.

One potential scenario of anticompetitive conduct is horizontal price fixing between the five insurers (Aetna, Cigna, Elevance, Humana, UnitedHealthcare) and Zelis, which the court said plausibly competes as a fellow purchaser of out-of-network healthcare services. Even if that argument ultimately falls short, Murphy indicated that allegations of a hub-and-spoke model (i.e., allowing for coordination and data sharing among insurers) seem credible.

“Taken as a whole, these allegations are sufficient to infer plausibly an agreement to fix prices, rather than just independent parallel behavior,” the preliminary ruling states.

Recent rulings a mixed bag for insurers

In addition to rejecting the overall arguments from the defendants, the court rebuffed a claim from Humana that it should not be subject to the allegations because in 2024 it exited the commercial market at issue. Per the ruling, participation at an earlier stage of the possible conspiracy is sufficient grounds for the allegations to proceed.

Aetna, Elevance and UnitedHealthcare prevailed in an earlier matter before the court, where they requested that specific plaintiffs be required to pursue claims via arbitration rather than in the litigation. Even antitrust claims about out-of-network payments arguably are tied to provider contracts, according to the ruling:

If other providers join the case and their contractual language is found to be similar, the ruling could help the insurers avoid class-wide liability.

Wide scope in the MultiPlan case

In rulings thus far in the respective cases, Zelis is portrayed as a direct competitor for out-of-network services, while MultiPlan’s involvement is providing analytics to insurers that act as purchasers. Thus, Zelis faces claims of horizontal price-fixing (i.e., coordination among competitors) in addition to hub-and-spoke anticompetitive behavior. The allegations against MultiPlan center on the latter area.

Numerous cases against MultiPlan were consolidated as multidistrict litigation (MDL) at the Northern District of Illinois federal court in August 2024. The MDL since has grown significantly, including the addition of various state medical associations. MultiPlan’s co-defendants include Aetna, Blue Cross Blue Shield, Cigna, Elevance and UnitedHealthcare.

Individual plaintiffs are seeking to recoup the difference between the fair market value of their services and the actual payment. In 2020 alone, according to a consolidated complaint, MultiPlan’s platform used proprietary algorithms to facilitate underpayments that totaled $19 billion. The amount allegedly reached $6.4 billion in a single 2024 quarter. Damages are subject to mandatory tripling under federal antitrust law.

MultiPlan allegedly processes more than 80% of commercial out-of-network reimbursement claims nationwide.

“MultiPlan and major health insurer competitors orchestrated a price-fixing cartel that processes over 370,000 out-of-network claims daily at artificially depressed rates,” according to a 2025 statement by attorneys for the plaintiffs.

DOJ position on algorithm-based pricing coordination

Providers won a preliminary decision in June 2025, when Judge Matthew Kennelly (a Clinton nominee) declined MultiPlan’s motion to dismiss the claims. Among the disregarded arguments was that providers could collect the balance from patients if the providers were underpaid via the MultiPlan algorithm.

Insights in that ruling and in a Department of Justice (DOJ) filing during the early months of the Trump administration indicate that even in the absence of explicit collusion, algorithm-driven pricing and data-sharing arrangements could meet the legal threshold for coordinated behavior under the Sherman Act.

The Act can be violated by “using a common pricing algorithm … even if the competitors do not always use the algorithm in the same way,” the DOJ wrote. In addition, “competitors’ exchange of competitively sensitive information can violate Section 1 even if those exchanges occur through an intermediary.”

Bellwether trials and billions of dollars

The lengthy time span likely needed to resolve the MultiPlan litigation is suggested in the scheduling of the first of many “bellwether trials” (i.e., a test case to gauge the viability of the plaintiffs’ arguments in MDL) for December 2027. Among the more than 30 individual cases selected as bellwether trials for the MDL are those brought by Adventist, Ascension, Community Health Systems and Texas Health Resources.

Because the medical claims at issue allegedly represent more than three-quarters of all out-of-network services during the applicable time frame, the scope of the MDL could dwarf even the Blue Cross Blue Shield provider class-action case that spanned more than a decade and was settled in 2024 for $2.8 billion (offshoot litigation brought by providers that opted out of the settlement is continuing).