A dentist in Kansas filed on March 31 a U.S. antitrust lawsuit against multiple insurers, including Zelis Healthcare and UnitedHealth Group, accusing them of operating a price-fixing conspiracy to suppress out-of-network payments to dental providers.
In addition to Zelis and UnitedHealth, Dr. Dennis Ayer filed the suit against Elevance Health, Aetna, and the Cigna Group stating that they allegedly shared sensitive data and set reimbursement rates to enable the companies to stifle payments to providers for claims submitted for services that were out of insurance networks.
"By paying legitimate claims at a small fraction of the cost, Zelis, the Insurers, and their co-conspirators inflict financial harm on those providing OON (out-of-network) care and competitive harm to their practices," according to the lawsuit.
Ayer, who owns a practice in Leawood, KS, is requesting that the case be certified as a class-action lawsuit.
Starting in 2016, the insurance companies allegedly formally agreed to provide commercially sensitive information -- including claims, pricing, and contract details -- to Zelis. The companies reportedly provided this data, knowing that Zelis was collecting similar data from competitors and using it to reprice reimbursements paid by Zelis, Aetna, UnitedHealth, Elevance, and Cigna.
The insurers' alleged price-fixing conspiracy aimed to fix or suppress payments to dental and medical providers for services that were out of network, which reduced patients' options for medical or dental care, according to the lawsuit.
The suit claims that the prices were fixed by Zelis, giving its analytical tools its pricing and claims data along with the "confidential, proprietary, and competitively-sensitive claims, pricing, and contractual data from directly-competing Insurers." This was done in violation of the Sherman Act, according to the suit.
Due to these practices, dental providers either didn't collect the money they were due or had to decline care for certain patients.
"Members of the Zelis conspiracy harmed competition by delegating to Zelis industry-wide pricing and negotiating authority concerning the payment of claims submitted for OON services," according to the lawsuit.
