The largest health insurance company and medical technology vendor Xeris Inc. must face a lawsuit alleging they conspired to reduce out-of-network reimbursements to health care providers, a federal judge ruled March 30.
Judge Brian E. Murphy of the United States District Court for the District of Massachusetts ruled that the plaintiffs, made up of several medical, dental, and chiropractic providers from multiple states, plausibly asserted antitrust standing and damages in this case. The judge denied Mr. Zellis and the insurance company’s joint motion to dismiss.
The lawsuit centers on allegations brought by health care providers against Xellis, Aetna, Cigna, Elevance, Humana and UnitedHealth Group that the five major payers conspired to suppress out-of-network reimbursement rates through Xeris’ re-pricing tools.
The case began in March 2025 when Pacific Inpatient Medical Group filed a class action lawsuit against Zelis, Aetna, Cigna, Elevance, and Humana. The court subsequently consolidated the case with several related cases, and the plaintiffs filed an amended consolidated complaint in June.
In the lawsuit, the health care providers allege that Xeris collaborated with private commercial health insurance companies and payers, and at least one other competitor, to avoid competition for payment rates for out-of-network medical services.
“This conspiracy involves unlawful agreements, communications, coordination, and information sharing involving Xellis and the commercial payer defendants to conspire to suppress payments and set payment levels and thresholds for out-of-network health services, euphemistically known as ‘repricing.’ “Although it sounds neutral, such ‘repricing’ is not based on upfront payments or provider-payer negotiations, and only moves in one direction: lower prices,” the providers argue in the lawsuit.
Providers claim that Zelis’ tools force them to either “accept significantly revised down payments, engage in time-sensitive and unilateral ‘negotiations’ with Zelis, or file an ‘appeal’ with Zelis of the downwardly revised claims.”
Providers argue that these options rarely, if ever, result in increased payments and ultimately result in costs in the form of delays, if not further reductions in payments on the claims providers originally submitted.
In one example, plaintiff Pacific Inpatient Medical Group alleges that Xeris repriced its claims at an 88% discount, which the provider said was below market value.
Providers also claim they were effectively locked out of differential billing patients because they had no meaningful ability to negotiate reprice amounts.
In exchange for a downward adjustment to the provider’s out-of-network bill, Zelis
The percentage of money saved to payers is what providers claim in their lawsuits.
Zelis provides comprehensive network management, claims integrity, payment remittance solutions, and analytics services to healthcare organizations. The complaint focuses on the company’s established reimbursement solutions and reference-based pricing products. The company partners with more than 750 payers, including the top five national health plans, community health plans, TPAs, and self-insured employers, and millions of health care providers.
When contacted, a Zelis spokesperson said the company does not comment on ongoing litigation.
Insurance Business Magazine reported that Zelis previously denied the accusations, saying the complaints were false about its customers, its operations and the benefits it provides.
Vendor MultiPlan also faces antitrust and consumer protection claims in lawsuits brought by health care providers. Individual health plans and the American Medical Association filed suit against MultiPlan, leading to a multidistrict lawsuit that consolidated dozens of plaintiffs’ claims. They accuse the company of contracting with insurance companies (UnitedHealth Group, Elevance Health, Aetna, and Cigna are listed as “co-conspirators”) to use common aggregate data sets and methodologies to set out-of-network prices rather than competing with each other individually.
In the lawsuit, the insurers likened their contracts with co-defendant insurers, including UnitedHealth Group, Elevance Health, Aetna and Cigna, to a “cartel” in which they colluded and shared confidential information to suppress premiums. The company countered that its reimbursement recommendation product uses publicly available data sources, rather than competitor data, when making recommendations to managed care organizations and third-party administrators.
