Quick Summary
- Arizona has filed a lawsuit against MultiPlan and several major health insurers
- The lawsuit alleges the companies used a shared algorithm to reduce out-of-network provider payments
- Providers allegedly received artificially low reimbursement rates across multiple insurers
- Patients may have faced higher out-of-pocket costs despite paying for out-of-network coverage
- The case highlights growing scrutiny of payer reimbursement practices, algorithms, and provider payment integrity
Arizona Challenges Alleged Out-of-Network Payment Practices
Arizona Attorney General Kris Mayes has filed a lawsuit against MultiPlan and several major health insurers, alleging they participated in a coordinated system that reduced payments to doctors and hospitals for out-of-network care.
The lawsuit names MultiPlan, now known as Claritev, along with Aetna, Cigna, UnitedHealthcare, Humana, Elevance, Molina, Centene, and Health Care Service Corp. According to the complaint, the companies allegedly relied on a shared algorithm and confidential claims payment data to determine reimbursement for out-of-network services.
Rather than setting payments independently, the lawsuit claims insurers used the same formula and delegated payment negotiation decisions to MultiPlan. Arizona alleges this resulted in extremely low provider payments that continued to decrease over time.
How the Alleged System Worked
According to the complaint, MultiPlan guided insurers in setting reimbursement rates for out-of-network care using an algorithm that allegedly produced low payment recommendations regardless of where care was provided. Arizona also claims insurers shared confidential claims data with MultiPlan, allowing reimbursement rates to continue declining over time.
Arizona also alleges that providers had little meaningful ability to negotiate. Doctors and hospitals challenging low payments allegedly faced pressure to accept reduced amounts, while MultiPlan and insurers benefited financially from the savings generated by lower reimbursements.
Impact on Providers and Patients
The lawsuit argues that the alleged system harmed both providers and patients. Providers were allegedly deprived of fair payment and, in some cases, forced to accept reimbursement below the cost of delivering care. Reduced reimbursement can create financial strain for providers, particularly those serving rural and vulnerable communities.
Patients may also be affected. According to the complaint, some individuals who paid higher premiums for out-of-network coverage were still left with large medical bills because insurers paid providers so little. Arizona argues that this undermined the value of PPO coverage and increased the risk of unexpected patient financial responsibility.
Legal Claims and Requested Relief
The state alleges that the defendants violated the Arizona Uniform State Antitrust Act and the Arizona Consumer Fraud Act. Arizona claims the companies acted together rather than competing independently and failed to fully disclose the role a third-party algorithm played in determining provider payments.
The attorney general is asking the court to stop the alleged conduct, return money to patients, providers, and employers who were harmed, require the companies to surrender profits tied to the alleged scheme, and impose civil penalties.
MultiPlan and the insurers have denied wrongdoing and maintain that their practices comply with applicable law.
What This Means for Healthcare Providers
This lawsuit reflects increasing scrutiny of payer reimbursement practices and the use of data-driven tools in healthcare payment decisions. Providers should closely monitor out-of-network reimbursement trends, payer communications, and underpayment patterns that may indicate broader systemic issues.
Strong documentation, payment tracking, and appeal processes are essential for identifying reimbursement discrepancies and protecting revenue.
How Patriot Group Can Help
As payer reimbursement practices continue to evolve, healthcare providers need effective strategies to identify underpayments, challenge improper reductions, and protect financial performance.
Patriot Group works with healthcare organizations to review payer payment patterns, support revenue recovery efforts, and address reimbursement disputes. If your organization is facing out-of-network payment challenges, payer underpayments, or complex claims issues, Patriot Group is available to help.
