Several major health insurers and Zelis Healthcare LLC, a third-party health cost management company, are now defendants in multiple class action lawsuits alleging a conspiracy to suppress payments to out-of-network healthcare providers. Filed in federal courts in California, Massachusetts, and Kansas, the suits claim that Zelis and insurers including Aetna, Cigna, Elevance Health, and Humana coordinated efforts to reduce reimbursement rates, raising significant antitrust concerns.
According to the most recent complaint, filed by Danny Bachoua Chiropractic, Zelis and the insurers allegedly communicated and aligned their pricing strategies to obtain extreme discounts, sometimes up to 98% off provider invoices. Rather than operating as independent competitors, the complaint argues, the insurers leveraged Zelis’ repricing tools to implement uniform cost reductions that harmed out-of-network providers.
Zelis has denied the accusations, stating that the complaints are mistaken about the identity of Zelis’s clients, the operation of Zelis’s solutions, and the benefits Zelis provides. The company claims its pricing tools are independently used by clients and that nothing in its services is unlawful. In its public response, Zelis emphasized its commitment to transparency and expressed confidence in prevailing in court.
These cases mirror a wave of ongoing antitrust litigation against MultiPlan Inc., another repricing company, currently pending in the Northern District of Illinois. While MultiPlan has moved to dismiss the cases, the legal questions raised are strikingly similar, namely whether repricers and payers are unlawfully suppressing market rates through coordinated strategies.
With increased legal attention on cost containment and repricing tools, healthcare providers must evaluate the implications for their out-of-network reimbursement practices. Legal exposure could arise not only from payer disputes but also from perceived participation in pricing schemes, even inadvertently.
If your practice is facing reimbursement challenges, audits, or legal risk involving repricing arrangements, contact Thomas J. Force, Esq., President and Founder of Patriot Group, at [email protected] or call (631) 870-4040. Patriot Group offers legal and compliance support to help healthcare organizations stay protected in a rapidly evolving regulatory landscape.
