Out-of-network (OON) repricing, a cost-control tool used by insurers and self-funded employer plans, has lost another round in court after a California appeals court ruled that insurer reimbursements to providers are prices subject to antitrust law.
The unanimous First Appellate District decision, certified for publication on September 21, 2026, revives claims by the VHS Liquidating Trust against MultiPlan Corporation, now called Claritev.
The trust's complaint covers insurers and self-funded payors, typically large employers that self-insure and contract with insurers and MultiPlan to administer their plans.
An ERISA Industry Committee report puts employer coverage at about 154 million non-elderly Americans, with 67% of covered workers in self-funded plans and 80% at firms of 200 or more staff.
Out-of-network repricing arrangements already face ERISA challenges. In a class action, members of self-funded plans administered by UnitedHealthcare allege the insurer used discounted repricer rates instead of the competitive fees their plans promised, which left members owing the rest of providers' bills.
ERISA requires sponsors to act in members' interests. If the MultiPlan antitrust theory holds up at trial, plans that contracted with MultiPlan or a similar platform could face governance questions.
A Phia Group survey of 124 brokers and advisors found only 12% very confident that clients have adequate fiduciary processes, while 76% said their books had moved toward self-funding in the past year.
Read more: Benefits brokers see fiduciary gaps clients aren't asking about yet, survey finds
The ruling adds a new legal dimension to how OON rates are set and challenged, while the No Surprises Act's independent dispute resolution (IDR) process already handles many OON payment disputes.
Georgetown University researchers found the process has generated $22.4 billion in costs since launch. Some 2.6 million disputes were filed in 2025, up 77% on the year before, and providers won 85% of the disputes decided that year.
The San Francisco trial court had treated OON reimbursement as "part and parcel of a health insurance policy."
The appeals panel found "no basis for exempting this category of payments from the broad reach" of the Cartwright Act, and said they would count as prices under federal law too.
The panel also relied on a 2025 ruling in the federal MultiPlan litigation in Illinois.
That litigation has consolidated more than 100 provider lawsuits against MultiPlan and major insurers, and the Justice Department filed a statement of interest in March 2025.
A Massachusetts federal judge let providers pursue Aetna, Cigna, Elevance, Humana and UnitedHealth over Zelis repricing, and said lower prices do not justify price-fixing agreements.
The complaint says insurers send OON claims to MultiPlan, whose algorithm draws on a database of 1 billion claims and which charges insurers about 5% to 7% of the difference between the original and repriced claim amounts.
More than 700 insurers use the service, including all 15 of the largest US health insurers as of January 2024, and it was repricing 370,000 OON claims a day by 2020.
Insurers allegedly pay MultiPlan's recommended rates 87% of the time "without any human touch," and 95% with human review.
MultiPlan has estimated that providers accept repriced inpatient OON amounts 93% to 99.4% of the time.
The complaint describes MultiPlan as the hub of "a traditional 'hub, spoke, and rim' agreement." It traces the conduct to Ingenix, a former UnitedHealthcare unit whose schedules allegedly understated market rates by up to 28%, and which New York's attorney general pursued in 2009.
Insurers settled related class actions for more than $2 billion and funded the FAIR database, but VHS alleges major insurers "continued essentially the same conduct through MultiPlan."
A lawsuit from HealthLGX claims that payments suppressed from about 2015 by insurers using MultiPlan fed into FAIR Health's benchmarks, so even insurers that never used MultiPlan allegedly paid less.
Read next: New lawsuit accuses MultiPlan, insurers of out-of-network pricing "cartel"
Claritev denies wrongdoing. A spokesperson said in June the company is not a health insurer, does not set OON reimbursement rates and does not make final payment or coverage decisions for clients.
The trust liquidates Verity Health System of California, which operated six not-for-profit hospitals before filing for bankruptcy in 2018. It sued in September 2021 and says depressed reimbursements caused it significant harm.
"The Court made clear that if insurers coordinate the amounts they pay hospitals and physicians, that's price fixing. Calling it 'repricing' doesn't change what it is - price fixing. And that's illegal per se," said Patrick M. Ryan, the trust's lead appellate counsel at Bartko Pavia.
The court gave no view on the merits. It sent the case back to address MultiPlan's other arguments and awarded VHS its costs on appeal.
