And why your billing partner’s expertise has never mattered more.
By Elena Pak, Credentialing Department, WCH
The $19 Billion Problem No One Was Talking About
For years, out-of-network reimbursement felt like a black box. You submitted a claim, a number came back — lower than expected, almost always — and the explanation was vague: “repriced per contracted methodology.” Most providers accepted it. Some appealed. Almost no one won.
Now we know why.
A wave of major antitrust lawsuits — against pricing vendors MultiPlan (now Claritev) and Zelis, alongside insurers including Aetna, Cigna, UnitedHealthcare, Elevance, and Humana — is pulling back the curtain on what plaintiffs describe as a coordinated system designed to suppress out-of-network payments at scale. The numbers in the litigation are staggering: court filings allege that in 2020 alone, MultiPlan’s algorithms facilitated $19 billion in underpayments, with plaintiffs claiming that figure reached $6.4 billion in a single quarter of 2024.
These figures are plaintiff-claimed and have not been adjudicated. But federal courts have declined to dismiss the underlying cases — and that alone is significant.
How the Alleged Scheme Worked
The mechanics, as laid out in court filings, are worth understanding clearly.
MultiPlan and Zelis operate as intermediaries between insurers and providers. When an out-of-network claim comes in, instead of each insurer independently determining what to pay, they route claims through these vendors’ proprietary repricing tools. The tools apply algorithms — drawing on pooled payer data, proprietary fee schedules, and reference-based pricing benchmarks — and spit out a payment figure.
Plaintiffs argue this is not a neutral service. It is, they allege, a hub-and-spoke pricing cartel: the vendors act as the hub, the insurers as the spokes, and the result is coordinated price suppression that no single insurer could achieve acting alone — and that would be obviously illegal if they tried.
The legal framing matters. In June 2025, a federal judge declined to dismiss the MultiPlan case, specifically noting that algorithm-driven pricing coordination can meet the legal threshold for anticompetitive conduct even without explicit collusion. The Department of Justice reinforced this view, writing that competitors can violate the Sherman Act by “using a common pricing algorithm… even if the competitors do not always use the algorithm in the same way.”
For the Zelis case, a Massachusetts federal judge went further in March 2026, finding — based on provider allegations cited in the ruling — that the vendor’s repriced claims function as a “take-it-or-leave-it” proposition, not a starting point for negotiation. Appeals processes were characterized in court filings as “effectively nonexistent.” The court found these allegations sufficiently credible to allow the case to proceed.
What Is Actually at Stake
The scale of the MultiPlan multidistrict litigation (MDL), consolidated at the Northern District of Illinois, is difficult to overstate. Among the plaintiffs are Adventist Health, Ascension, Community Health Systems, and Texas Health Resources, along with numerous state medical associations. The first bellwether trial is scheduled for December 2027, meaning final resolution is still years away.
For context: the Blue Cross Blue Shield provider class-action case — one of the largest in healthcare antitrust history — took over a decade and settled in 2024 for $2.8 billion. The MultiPlan MDL could exceed it substantially.
The Zelis case is earlier in its trajectory but moving. And critically, the legal theories being validated in both cases — hub-and-spoke coordination, algorithm-as-conspiracy, data-sharing through intermediaries — are establishing precedent that will shape the industry for decades.
What This Means for Your Practice Right Now
The lawsuits will take years to resolve. But the underlying dynamic they expose is happening today, in your remittances, in your EOBs, in the gap between what you billed and what you received.
Most practices track what was paid. Very few track what should have been paid. That gap is where revenue disappears — quietly, systematically, and in ways that look routine until someone examines them closely.
Several practical conclusions follow.
Every out-of-network underpayment deserves scrutiny. If your claims are being repriced through MultiPlan or Zelis tools, you may be receiving less than fair market value — and the courts are now actively examining whether that repricing was legitimate at all. This is not a reason to panic, but it is a reason to pay close attention to how your out-of-network reimbursements are calculated and documented.
Most practices under-appeal out-of-network claims — not because they lack grounds, but because they lack infrastructure. One of the core findings in the Zelis ruling was that appeals processes have been described by providers as effectively inaccessible — suggesting the system is designed to discourage challenge. That design should be challenged. A skilled billing team identifies when and how to push back, and does so systematically rather than case by case.
Documentation is your protection. In an environment where payer conduct is under legal scrutiny, your own records — of what was billed, what was paid, what was appealed, and on what grounds — are your primary asset. Incomplete documentation is a liability. Rigorous documentation is leverage.
Coordination and transparency from your biller is not optional. The complexity these lawsuits expose — repricing methodologies, fee schedule benchmarks, payer coordination patterns — erodes revenue silently when you don’t have expert eyes on it. Most practices cannot monitor this internally. That is precisely why professional revenue cycle management exists.
The Broader Shift: Algorithms Are Not Neutral
There is a deeper point here that goes beyond these specific lawsuits.
Healthcare reimbursement has been increasingly automated, increasingly opaque, and increasingly mediated by third-party tools whose incentives do not align with providers. The MultiPlan and Zelis cases are, at their core, a legal reckoning with a system that outsourced pricing decisions to black boxes — and structured those black boxes to benefit payers at providers’ expense.
The DOJ’s position in the MultiPlan case is a signal that regulators are paying attention. The judicial findings — that algorithmic coordination can constitute anticompetitive behavior, that data sharing through intermediaries can violate antitrust law — are a signal that the law is catching up to the technology.
For providers, the practical implication is this: you cannot assume that what a payer or its repricing vendor tells you is fair, accurate, or legally defensible. You need people on your side who understand the system — its mechanics, its failure points, and your rights within it.
Why Expertise in Billing Has Never Been More Consequential
The era when medical billing was primarily a clerical function — submit the claim, post the payment, move on — is over. What these lawsuits make visible is that billing sits at the intersection of clinical documentation, payer contract interpretation, regulatory compliance, and now antitrust law.
This is the environment in which WCH Service Bureau operates. Founded in 2001 and serving thousands of providers across New York, New Jersey, Pennsylvania, California, and beyond, WCH has spent over two decades doing what the current litigation proves providers cannot afford to skip: scrutinizing what should have been paid, not just what was.
That means systematic appeals infrastructure — not reactive, case-by-case pushback, but a process designed to identify underpayments before they become accepted baselines. It means chart auditing that protects you from both revenue loss and compliance exposure. And it means the kind of long-standing payer relationships that translate into faster resolution and fewer write-offs.
The lawsuits against MultiPlan and Zelis are, ultimately, about information asymmetry: payers knew what was happening; providers did not. The answer to information asymmetry is expertise, transparency, and a billing partner whose interests are fully aligned with yours.
***
The MultiPlan and Zelis litigation may take years to resolve, and individual providers are unlikely to recover losses through the courts directly. But these cases are clarifying something important: the reimbursement system has not been working the way it was supposed to, and the law is beginning to say so explicitly.
The response, for any practice serious about its financial health, is not to wait for the courts. It is to demand better — from your payers, from your billing processes, and from the partners you trust to manage your revenue.
Because the algorithm has been underpaying you. And the question is what you are going to do about it.
Sources
- Out-of-network pricing lawsuits test MultiPlan, Zelis business models — Healthcare Dive / Nick Hut, April 20–21, 2026
- U.S. District Court of Massachusetts — Ruling on Zelis motion to dismiss, Judge Brian Murphy, March 2026
- U.S. District Court, Northern District of Illinois — MultiPlan MDL, ruling on motion to dismiss, Judge Matthew Kennelly, June 2025
- U.S. Department of Justice — Amicus filing in MultiPlan MDL, 2025
- Sherman Antitrust Act, 15 U.S.C. § 1
- Blue Cross Blue Shield Provider Antitrust Settlement, 2024
- WCH Service Bureau — wchsb.com
Discover more from Doctor Trusted
Subscribe to get the latest posts sent to your email.
