Five of the largest health insurers and health tech vendor Zelis must face claims that they conspired to reduce out-of-network reimbursements to healthcare providers, a federal judge ruled on March 30.
Judge Brian E. Murphy of the U.S. District Court for the District of Massachusetts ruled that the plaintiffs, comprising several medical, dental and chiropractic providers from multiple states, plausibly alleged antitrust standing and injury in the case. The judge denied Zelis and the insurance companies' joint motion to dismiss.
The case centers on allegations brought by healthcare providers against Zelis and Aetna, Cigna, Elevance, Humana and UnitedHealth Group that the five major payers conspired to suppress out-of-network reimbursement rates through Zelis' repricing tools.
The litigation began in March 2025, when Pacific Inpatient Medical Group filed a class action lawsuit against Zelis, Aetna, Cigna, Elevance and Humana. The court then consolidated the case with several related actions and the plaintiffs filed an amended consolidated complaint in June.
In the lawsuit, the providers allege that Zelis collaborated with private commercial health insurers and payers, and at least one other competitor, to avoid competition over payment rates for out-of-network healthcare services.
"The conspiracy involves the unlawful agreement, communication, coordination, and information sharing, as engaged in by Zelis and the commercial payer defendants, designed to collusively depress and set payments and payment levels or thresholds for out-of-network healthcare services, euphemistically known as 'repricing.' Even if neutral sounding, such 'repricing' is not based on any pre-payment, provider-payer negotiation, and goes only one direction: down," the providers allege in the lawsuit.
The providers claim that Zelis' tool forces them to either accept the "severely downwardly adjusted amount as payment; to engage in time-pressured and one-sided 'negotiations' with Zelis; or to file an 'appeal' of the downwardly-adjusted claim with Zelis," the providers said.
These options rarely, if ever, result in an increase in the payment and ultimately result in the incursion of an expense in the form of delay, if not a further decrease in payment of the provider’s originally submitted claim, the providers allege.
For example, plaintiff Pacific Inpatient Medical Group alleges that Zelis repriced a claim at a discount of 88%, which the provider said was below market prices.
The providers also claim they had no meaningful ability to negotiate those repriced amounts, and that they were effectively barred from balance-billing patients.
In exchange for its downward adjustment of providers' out-of-network claims, Zelis receives a percentage of the amount that the payer saves, the providers allege in the lawsuit.
Zelis provides a comprehensive array of network management, claims integrity, payment remittance solutions and analytical services to healthcare organizations. The complaint centers on the company's Established Reimbursement Solution and Reference Based Pricing products. The company works with more than 750 payers, including the top five national health plans, regional health plans, TPAs and self-insured employers, and millions of healthcare providers.
When contacted, a Zelis spokesperson issued a statement: "Last week’s motion was procedural and does not change Zelis’ position. Zelis operates with a strong commitment to integrity, transparency, and full compliance with all applicable laws and regulations. Zelis uses common, publicly available data sources when making its recommendations to managed care organizations and third-party administrators. We remain confident the facts will show these lawsuits are without merit."
Insurance Business Magazine reported that Zelis previously denied the accusations, stating the complaints are mistaken about its clients, operations and the benefits it provides.
Vendor MultiPlan is also facing antitrust and consumer protection claims in litigation brought by healthcare providers. Individual health systems and the American Medical Association have filed cases against MultiPlan, leading to multidistrict litigation consolidating dozens of plaintiff complaints. They accuse the company of forming agreements with insurers—UnitedHealth Group, Elevance Health, Aetna and Cigna are listed as "co-conspirators"—to set out-of-network prices using a common collective data set and methodology, as opposed to competing with each other individually.
In their lawsuits, providers likened the agreements with codefendant insurers such as UnitedHealth Group, Elevance Health, Aetna and Cigna to a collusive “cartel,” arguing that they share confidential information to suppress rates. The company has countered that its reimbursement recommendation product uses common, publicly available data sources, not competitor data, when making its recommendations to managed care organizations and third-party administrators.
Editor's Note: This story has been updated with a statement from Zelis.