Judge Allows Docs' Lawsuit Against MultiPlan to Proceed

Medscape

a day ago

A district judge has ruled that physicians can move forward with a federal lawsuit that accuses insurers and an analytics company of underpaying them by billions through a price-fixing scheme for out-of-network services.
In a June 3 decision, US District Judge Matthew Kennelly wrote that providers have alleged a direct injury from the reported price-fixing agreement and that their antitrust claims against data company MultiPlan are valid.
The ruling addresses two consolidated complaints by several plaintiffs, including the American Medical Association (AMA) and the Illinois State Medical Society (ISMS), against MultiPlan, which has now changed its name to Claritev.
The medical associations claim MultiPlan/Claritev and third-party payers violated federal and state antitrust laws with a price-fixing conspiracy that forced physicians to accept increasingly low payments for out-of-network services. The suit names Aetna, Cigna, UnitedHealth Group, and Health Care Service Corporation, a Mutual Legal Reserve Company, as 'co-conspirators' in the complaint, among other 'smaller' insurers.
AMA President Bruce A. Scott, MD, praised the court for allowing the case to proceed, calling the ruling 'the clearest statement yet by a court that MultiPlan's lack of transparency, accuracy, and integrity in the insurer-run system for paying out-of-network medical bills is an antitrust violation.'
'MultiPlan and the commercial health insurance companies have profited from the rigged system while forcing physicians to accept lower and lower payment amounts for out-of-network services — payments that in many cases do not cover the cost of delivering care to patients,' Scott said in a media statement. 'Ending this conspiracy is a good start toward creating an open and honest system that will restore fair reimbursements and help ensure patients have access to the care they need.'
A Claritev spokeswoman told Medscape Medical News in an email that the company remains 'confident that the facts will reinforce what we've consistently said — that these lawsuits are without merit and fail to acknowledge the critical role our competitive options play in reducing healthcare costs for employers and improving access for patients.'
'These lawsuits will only serve to increase healthcare [costs] for employers and patients. We will vigorously defend ourselves through the legal process while remaining focused on delivering value to our customers and the broader healthcare ecosystem.'
ISMS President Richard C. Anderson, MD, said the medical society appreciates the ruling and that it's 'time for MultiPlan to face the music.'
'The company can change its name, but it doesn't change the fact that they reaped huge profits from this price-fixing collusion,' Anderson wrote in an email to Medscape Medical News . 'They routinely paid below-market reimbursement rates to physician for out-of-network healthcare services with no transparency in their process. Patients and physicians deserve better.'
Alleged Price-Fixing Conspiracy
On its website, Claritev describes itself as a healthcare technology, data, and insights company that focuses on improving affordability, transparency, and quality.
The company offers an alternative method for calculating a third-party payer's out-of-network rate through its Data iSight algorithm, according to court records. Data iSight calculates rates by referencing the cost of the service to the provider and the median payment for similar services rendered, according to the legal summary. Using these metrics, the algorithm tends to produce lower payment rates than Usual, Customary, and Reasonable benchmarks.
If payers agree to use a Data iSight-calculated rate, the company offers to negotiate the rate with providers on behalf of the insurer. During the negotiation, MultiPlan/Claritev conditions all payments on a provider's agreement not to balance bill the patient, according to the legal summary.
The plaintiffs allege the company's rates are provided on a 'take-it-or-leave-it' basis and that they were unable to convince the company to deviate from a Data iSight-calculated rate.
Providers can still decline MultiPlan's offer and seek payment directly from the patient and the insurer, according to court documents.
An April 2020 study by the Office of the New York State Comptroller found that payments based on MultiPlan's repricing methodology at the time were 1.5-49 times lower than payments for the same services based on the traditional method of calculating out-of-network payment rates for physicians, according to the AMA.
The physician plaintiffs contend the company undercuts fair payment for out-of-network healthcare services and eliminates market competition. The 'widespread conspiracy' between the company and insurers has forced many medical practices to shut down, cease offering certain services, or seek other employment arrangements, according to their complaint.
Insurers have contracted with MultiPlan to use its Data iSight algorithm and negotiation services since 2015, and by 2018, hundreds of third-party payers had contracts with the company, according to court records. The company grew to having contracts with more than 700 third-party payers and, in 2019, processed more than 80% of out-of-network healthcare service payments, according to court documents.
A 2024 New York Times investigation found that both the company and insurers made more money when then-MultiPlan lowered fees paid to physicians for out-of-network services. In May 2024, Ron Wyden (D-Oregon) and Bernie Sanders (I-Vermont), US senators, requested more information from MultiPlan, expressing concern that the company might be driving up costs for consumers.
Sen. Amy Klobuchar (D-Minnesota) also sent a letter to the Federal Trade Commission in May 2024, seeking an investigation into what she deemed 'potentially anticompetitive conduct.'
Company Argues Claims Invalid
MultiPlan/Claritev asked the court to throw out the complaint, arguing the plaintiffs have not asserted a viable federal antitrust claim because they have not proven antitrust standing nor shown how the company violated antitrust law.
Even if the providers are getting below-market payments, the company said the doctors have failed to allege the lesser payments are due to a harm to competition. Rather, MultiPlan/Claritev's services increase competition by providing another rate calculation option, and its services are further beneficial because they lower costs to third-party payers and patients, the company's attorneys argued.
In addition, the company contended that providers have not been directly injured by the alleged party payer agreement to fix prices because 'they can always seek full payment from the patient.'
However, Kennelly wrote that the providers have alleged a direct injury because the alleged balance billing prohibition prevents providers from seeking the remaining payment from patients and 'shields patients from the consequences of the alleged third-party payor price-fixing agreement.'
If MultiPlan/Claritev's services are harmful or beneficial to competition is a matter for further court analysis, Kennelly also said.
'Whether MultiPlan facilitates a third-party payor price-fixing agreement or is simply another pricing option for payors is a factual dispute that cannot be resolved on a motion to dismiss,' he wrote in his ruling.
The judge, however, dismissed the plaintiffs' unjust enrichment claims against the company. Kennelly wrote the physicians failed to allege an unjust enrichment claim under a specific state law.
A case management conference in the case is scheduled for June 17.