10/05/2026

Ohio Physicians Are Speaking Out About Out-of-Network Payments

by Jason Koma
Chief Executive Officer, Ohio State Medical Association

Across Ohio, physicians provide medically necessary care on a daily basis, often in emergencies or in specialties where there are no in-network options available for patients, and yet these physicians receive insurance reimbursement for that care that bears little resemblance to what that care cost to deliver. This financial burden is unfortunately  a major contributor to hospital and practice closures we see here and across the country.

According to a major federal antitrust lawsuit now moving through the courts, this phenomenon is driven by price fixing, not by market forces.

The MultiPlan litigation, which consolidates claims brought by hundreds of healthcare providers, alleges that Claritev (which recently rebranded from MultiPlan) worked with the nation’s major payors (including Aetna, Cigna, Elevance Health, and UnitedHealth Group) and others to create and operate a system that greatly reduced or eliminated competition in the market for out-of-network care. Instead of determining payments independently, these payors stopped competing with each other and instead outsourced their rate-setting responsibilities to Claritev, which then used algorithm-driven pricing systems to artificially drive payments downward for all the payors. Those shared rates were far less than rates that would have been set in a competitive market. The defendants deny these allegations.

The plaintiffs’ allegations describe a system with extraordinary reach. By 2020, Claritev reportedly processed more than 370,000 out-of-network claims each day, representing more than 80 percent of commercial out-of-network reimbursements nationwide. According to the lawsuit, providers were underpaid by approximately $19 billion in 2020 alone.

So far, the momentum has been on the plaintiffs’ side in the litigation. In March 2025, the Department of Justice filed a statement of interest in the case, arguing that competitors can violate federal antitrust law by exchanging competitively sensitive pricing information through a third-party intermediary, even if they never communicate directly with one another. In June of that year, the presiding judge— U.S. District Judge Matthew F. Kennelly of the Northern District of Illinois—ruled that if proven true at trial, the plaintiffs’ allegations would establish violations of federal and state antitrust and unfair competition laws. He therefore allowed the litigation to proceed into the evidence-gathering phase.

Then, on June 24 of this year, Judge Kennelly rejected an attempt by the defendants to avoid liability based on their argument that providers' alleged billing irregularities should prevent them from pursuing their claims altogether. Judge Kennelly ruled that even if billing disputes exist and defendants could prove their allegations at trial, these issues could at most affect the amount of damages the plaintiffs may ultimately recover, and they do not excuse or justify the defendants’ alleged conspiracy to suppress reimbursement rates.

These developments and rulings did not decide the merits of the case, and the plaintiffs still must prove their allegations. But they do ensure that serious allegations about how out-of-network reimbursement has operated for years will continue to receive a full hearing in federal court.

The MultiPlan proceedings cast a spotlight on problems that physicians across the country have long recognized because they have live with them every day. Many have watched reimbursement for out-of-network care decline dramatically while the process for determining those payments has become increasingly opaque. When reimbursement no longer reflects the resources required to deliver care, the effects ripple throughout the healthcare system.

That is why the Ohio State Medical Association (OSMA) joined this litigation on behalf of our members, and why individual providers who believe they have been affected may also be able to pursue their own claims and recover damages. This case is not simply about resolving past payment disputes. It raises fundamental questions about whether healthcare markets should operate through fair competition or through a reimbursement system that has allegedly allowed dominant insurers to dictate prices with little transparency or accountability.

When physicians cannot sustain independent practices, patients lose access to specialists. When behavioral health providers and addiction treatment centers cannot remain financially viable, communities lose critical services. When rural hospitals struggle under persistent reimbursement pressures, entire regions may lose access to emergency and specialty care. These are not abstract economic concerns. This leads to very real questions about whether patients can obtain timely medical care close to home. They are, truly, issues of life and death.

As this litigation moves forward, OSMA hopes it leads not only to accountability where appropriate, but also to a broader conversation about ensuring that reimbursement systems strengthen, rather than undermine, access to quality healthcare in Ohio and across the country.