AdventHealth sued MultiPlan for allegedly colluding with other insurers to shortchange providers for care offered outside of an insurance company’s network, the latest example of the litigious relationship between health systems, physicians and insurers.
The 50-hospital system based in Altamonte Springs, Florida, accused MultiPlan of forming “an ongoing cartel agreement with competing health insurance companies throughout the U.S. to bilk healthcare providers of billions of dollars per year,” alleged the complaint filed last week in the U.S. District Court for the Southern District of New York. MultiPlan allegedly uses analytics software to systematically underpay out-of-network healthcare claims, according to the lawsuit, which also cited Aetna, Elevance Health (formerly Anthem), Centene, Cigna, Health Care Services Corp., UnitedHealth Group and Humana as "co-conspirators."
AdventHealth alleged that nationally, MultiPlan underpays healthcare providers $19 billion a year. The system seeks damages for the alleged underpayments and lost revenue amounting to “hundreds of millions of dollars.”
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AdventHealth declined to comment.
In a statement, MultiPlan said the lawsuit is without merit and the company “looks forward to disproving these baseless allegations.”
Hospital operators, doctors and health insurers have fought for decades about reimbursement, especially involving out-of-network care. Here are three other lawsuits.
SSM Health v. Bright Health
The Oklahoma division of St. Louis-based SSM Health filed a lawsuit in April against Bright Health, alleging it is owed nearly $13.1 million for services provided to the insurance company's members between Jan. 1, 2020 and Feb. 7, 2023.
Bright Health left the Oklahoma market, along with several other states, at the end of 2022 as it racked up losses and faced regulatory scrutiny.
Bright Health, which offered Oklahoma residents coverage through the Affordable Care Act's health insurance exchange marketplace, did not have a written contract with SSM and thus was not included in Bright Health’s network, SSM's suit filed in an Oklahoma federal court alleges. As a result, Bright Health must pay the “reasonable and customary charges billed by SSM” related to nearly 2,500 claims, the health system alleges.
The case is pending.
Envision, TeamHealth v. UnitedHealth
UnitedHealth Group, the nation’s largest insurer, and physician staffing companies continue to spar over out-of-network payment rates.
In March, the U.S. District Court for the Southern District of Florida ordered UnitedHealth to pay $91.2 million after the court ruled in favor of Nashville, Tennessee-based Envision Healthcare. The physician staffing company had alleged that UnitedHealth Group violated a contract by “unilaterally” reducing reimbursements and refusing to accept its physicians into insurance networks. Envision filed for Chapter 11 bankruptcy protection in May.
UnitedHealth has been involved in multiple lawsuits with Knoxville, Tennessee-based TeamHealth. A Florida court ruled late last year that the insurer must pay $10.8 million to resolve allegations it underpaid TeamHealth subsidiary Gulf-to-Bay Anesthesiology Associates from 2017 to 2020. A UnitedHealth spokesperson said after the December ruling that TeamHealth “uses litigation to distract from the real reason it no longer participates in our network: It expects to be paid double or even triple the median rate we pay other physicians providing the same services.”
Multiple other lawsuits are pending between UnitedHealth and TeamHealth, which offers outsourced emergency services to hospitals. Legislators have cited related cases and studies as justification for passing the No Surprises Act, which prevents providers from billing privately insured patients more than typical in-network, out-of-pocket costs for most emergency services, excluding ground ambulance transportation.
Prime Healthcare v. Aetna
Prime Healthcare sued multiple insurers including Aetna in June 2016, alleging they underpaid its hospitals for treating patients out-of-network. The chief complaint was against Aetna; Prime filed several lawsuits against five other insurers.
Ontario, California-based Prime alleged that insurers “have demanded such low rates and have become so onerous and one-sided” that they have forced Prime to not accept in-network rates. As an out-of-network providers, the insurers have “drastically underpaid hospitals” by using “flawed methodologies” in how they determine usual, customary and reasonable rates.
Prime and Aetna agreed to dismiss the case in October 2016. The other lawsuits were dismissed by early 2017.
