by John R. Fischer
, Senior Reporter | August 16, 2023
AdventHealth has accused insurer MultiPlan of carrying out a years-long conspiracy that allowed it and other major health insurers to deprive healthcare providers nationwide of $19 billion annually in reimbursements owed for out-of-network services they performed.
The health system, which is based in Florida and is one of the largest nonprofits in the U.S. with over 50 hospitals in nine states, filed an antitrust lawsuit in Manhattan federal court on August 9. In it, AdventHealth alleges that MultiPlan used and sold to competitors analytical tools that calculated lower reimbursement rates than what an insurer would typically pay and what a provider would request in a claim.
By 2017, It had reached agreements with “nearly every other significant healthcare insurance payor in the United States,” said the complaint. The case is Adventist Health System Sunbelt Healthcare Corporation v. MultiPlan Inc., U.S. District Court, Southern District of New York, No. 1:23-cv-07031, according to Reuters
"The money that MultiPlan and competing payors withhold from healthcare providers does not go to patients; it goes to insurance companies, their investors, and their executives,” said AdventHealth in its suit.
A MultiPlan representative told Reuters that the company “believes this lawsuit has no merit and looks forward to disproving these baseless allegations."
In 2006, the company began acquiring the organizations that designed the tools and by 2020 was using them to underpay on 370,000 out-of-network claims per day for over 700 health insurance companies, an approximate deficit of $19 billion, said AdventistHealth. Rates were based on real-time, private pricing data supplied by MultiPlan’s member healthcare insurers.
Those alleged to have partaken in the scheme include major ones like CVS Health subsidiary Aetna, Cigna, UnitedHealth, and Humana. Representatives for these companies did not respond for comment.
MultiPlan has a Preferred Provider Organization (PPO) made up of multiple networks across the country of preferred healthcare providers that negotiate rates with it. Anticipating that providers could stop treating patients covered by its PPO, it sold the repricing technology to its competitors to make the repricing widespread. Additionally, providers who accepted the repriced claim forewent seeking compensation from any other source.
An analyst referenced in the lawsuit compared MultiPlan to a “mafia enforcer for insurers.”
AdventHealth is seeking unspecified monetary compensation for what it alleges was "significant economic losses from underpayments."