Out-of-network claim repricing is when a third party, most often MultiPlan, now rebranded Claritev, sets the payment amount an insurer sends a PT provider for out-of-network care, typically well below the billed rate. Claritev prices claims for more than 700 insurers, including all 15 of the largest US health plans, and insurers accept its recommended rate 87% of the time without human review. This isn't a settled legal gray area anymore: APTA and APTA Private Practice joined federal antitrust litigation against Claritev and major insurers in October 2025, and a California appellate court revived related claims in September 2026, ruling that insurer reimbursements are prices subject to antitrust law. Providers have no contract with the repricer and no obligation to accept its number. Below is what the No Surprises Act does and doesn't cover, what the litigation means practically, and how to protect your reimbursement.

Repricing Entities: What Are They?

Third-party repricing companies operate as specialized intermediaries within healthcare payment processing, specifically targeting out of network physical therapy claims. These entities fundamentally alter payment determination processes, making their operations essential knowledge for practice financial protection.

Definition of Third-Party Repricing Companies

Repricing entities function as data analytics companies contracted by insurers to establish payment amounts for out-of-network therapy services. These companies examine submitted claims and determine their version of "appropriate" payment rates, frequently reducing original billed amounts significantly. MultiPlan, now rebranded Claritev, dominates this sector, servicing approximately 700 of the nation's 1,100 insurers, including all 15 of the largest health plans, replacing independent out-of-network rate setting.

These organizations market themselves as cost containment specialists, promoting services that purportedly "reduce healthcare claims costs" and "realize significant savings" for insurance plans. Their actual function involves serving as intermediaries between providers and payers, applying proprietary algorithms drawn from a database of more than 1 billion claims to modify payment amounts for completed services.

Why and How Insurers Contract With Them

Insurance companies establish partnerships with repricing entities for direct financial benefit. This arrangement generates revenue streams for both parties through "shared savings fees," creating a specific business model:

• Repricing companies establish reduced payment amounts for providers

• The gap between original charges and repriced amounts becomes "savings"

• Insurers and repricing companies divide these "savings" as revenue, with Claritev charging insurers roughly 5% to 7% of the difference between the original and repriced claim amount, according to litigation records

Both entities maintain direct financial incentives to minimize provider payments. Insurers reportedly follow Claritev's recommended rate 87% of the time with no human review at all, and 95% of the time even when a human does review it.

The arrangement operates without contractual relationships between providers and repricing companies, unlike in-network insurer relationships where terms require mutual agreement.

How Repricing Works

Claim repricing mechanics reveal concerning practices that directly impact reimbursement levels for out-of-network physical therapy services. These processes require careful examination to protect your practice from unexpected payment reductions.

The Claimed "Usual, Customary, and Reasonable" (UCR) Pricing

Insurers processing out-of-network therapy claims typically state they reimburse providers based on "usual, customary, and reasonable" (UCR) amounts for services within a geographic area, generally described as what providers in the area usually charge for the same or similar service. This approach appears fair on its face, paying what other local providers typically charge for comparable services.

The American Medical Association clarifies UCR components:

• Usual: The fee an individual provider typically charges their patients

• Customary: Within the range of fees charged by similarly qualified providers in the same geographic area

• Reasonable: Meeting the above criteria plus justifiable considering special circumstances

Vague Calculation Methods

The concept appears straightforward, yet actual calculation methods remain remarkably opaque. Insurers and repricing entities use various methodologies lacking consistency or transparency. Some determine UCR based on undiscounted billed charges at the 80th or 75th percentile threshold, meaning 80% or 75% of providers in an area charge that amount or less.

Others claim to use Medicare fee allowances as the basis for negotiations, or proprietary data sets without public access. Most significantly, no standard definition exists under insurance laws, allowing each insurer or repricing company to create their own methods, which is part of what current litigation is challenging.

The Lack of Contract Between Provider and Repricing Company

As an out-of-network therapy provider, you maintain no contractual relationship with these repricing entities. Unlike in-network arrangements where you agree to specific fee schedules, repricing companies operate as third parties hired by insurers, not by you. This disconnect means they determine your payment rates without your input or consent.

Does the No Surprises Act Protect Out-of-Network PT Claims?

Mostly, no, and this is the detail most content on this topic gets wrong. The No Surprises Act's federal Independent Dispute Resolution (IDR) process applies specifically to three situations: out-of-network emergency services, out-of-network nonemergency services provided at an in-network facility, and out-of-network air ambulance services. A patient who knowingly and electively chooses to see an out-of-network PT at a freestanding outpatient clinic is not in a surprise billing situation, so that claim generally falls outside the NSA's protections and the IDR process.

Where IDR does apply, the process runs on a defined timeline: a 30-business-day open negotiation period between provider and insurer, and if that fails, either party can initiate federal IDR. A June 2026 final rule (91 Fed. Reg. 33900), effective in August 2026, standardized the claim adjustment and remittance codes insurers must use with out-of-network providers, intended to make it easier to determine IDR eligibility. More than 5.1 million dispute submissions have gone through IDR since the NSA took effect, far exceeding original federal projections.

Is Out-of-Network Repricing Legal? What the MultiPlan/Claritev Litigation Means for PTs

This is now an active, contested legal question, not a resolved one. APTA and APTA Private Practice joined the federal MultiPlan Antitrust Litigation as plaintiffs in October 2025, alongside the American Medical Association and hundreds of other provider organizations, alleging a coordinated scheme among Claritev and major insurers, including UnitedHealth, Elevance, Humana, Aetna, Cigna, and Blue Cross Blue Shield entities, to suppress out-of-network reimbursement since at least 2015.

On September 21, 2026, a California appellate court revived related antitrust claims (VHS Liquidating Trust v. Claritev), ruling that insurer reimbursements to providers are prices subject to antitrust law, a significant procedural win for providers even though it doesn't resolve the underlying case. A federal judge separately allowed providers to pursue similar claims against Aetna, Cigna, Elevance, Humana, and UnitedHealth over related repricing practices.

None of this means repricing is currently illegal or that payments are guaranteed to change. It means the practice is under serious, current legal challenge, and providers who've been out-of-network with major insurers may eventually be eligible for damages depending on how the litigation resolves. This is not legal advice; consult your own counsel or APTA's practice advisory resources for guidance specific to your situation.

Impact on Reimbursement

Claim repricing creates measurable financial damage across multiple levels of physical therapy practice operations. Payment reductions affect practice sustainability, provider compensation, and patient access to care.

Examples of Reduced Payments

Reliable current benchmarks are harder to find than the older statistics frequently cited on this topic, many of which predate the current litigation. What's consistently reported in litigation records: Claritev's fee structure means the incentive to reprice claims lower never goes away, and the company was processing 370,000 out-of-network claims a day as of 2020, a volume that has only grown since. The Multiple Procedure Payment Reduction (MPPR) policy separately creates reductions of up to 7% for typical therapy practices billing multiple services per visit.

Financial Impact on Practices

Payment reductions create direct consequences for practice viability. Compressed reimbursement pushes some PT private practices toward profit margins that threaten business survival, and rising operating costs compound the pressure. These financial pressures can force practice owners to reduce compensation for owners and therapists.

Effects on Patient Out-of-Pocket Costs

Patients bear part of the financial burden as well. When a repriced payment falls short of the billed amount, the gap often shifts to the patient's out-of-pocket responsibility. Higher out-of-pocket costs are broadly associated with patients delaying or reducing care, which is part of why transparent upfront communication about potential costs matters as much as the reimbursement fight itself.

Key Issues for Providers

Physical therapists offering out-of-network therapy services maintain specific rights when dealing with repricing entities. Recognizing these rights determines whether you accept drastically reduced payments or maintain fair compensation for your services.

No Obligation to Accept Repriced Payment

Physical therapists have no contractual obligation to accept reduced rates determined by third-party repricing companies. No contractual relationship exists between you as the provider and the repricing company. Accepting a patient with specific insurance coverage does not automatically commit you to accept whatever payment the insurer's contracted repricing entity determines appropriate.

Importance of Documentation and Patient Communication

Proper documentation provides your strongest defense against unfair repricing practices. Clinical documentation serves as more than a professional responsibility and legal requirement, it ensures patients receive appropriate, thorough care. Solid documentation demonstrates you met or exceeded standard care protocols, reducing practice risks.

Out of network physical therapy providers must communicate honestly with patients about potential costs. The APTA Practice Advisory (member benefit) provides background information plus practical steps to prevent underpayment, including managing out-of-network billing when repricing entities are involved, handling situations where discounted rates were already accepted, and taking action with patients and state insurance authorities.

How Can PT Clinics Protect Revenue From Out-of-Network Repricing?

Verify out-of-network benefits before the first visit, not after the claim comes back. Knowing a patient's out-of-network deductible, coinsurance, and any UCR-based limitations up front lets a clinic set accurate patient expectations before treatment starts. SPRY's eligibility verification checks this automatically rather than leaving it to a post-visit surprise.

Track repriced amounts against billed amounts by payer. A clinic that isn't tracking the gap between what it billed and what it actually got paid, broken out by insurer and repricer, can't tell whether a specific payer's out-of-network behavior is worsening. SPRY's reporting and analytics surface payment trends by payer so patterns show up before they become a systemic revenue problem.

Give patients transparent, upfront cost estimates. Since repricing shifts more of the balance to the patient, clear invoicing prevents billing disputes and protects the patient relationship. Automated patient invoicing generates estimates based on verified benefits rather than guesswork.

Document medical necessity and treatment thoroughly. Solid clinical documentation is the strongest tool available when appealing a repriced or underpaid claim, regardless of how the antitrust litigation eventually resolves.

Summary & Takeaways

Out-of-network physical therapy practices confront a critical financial challenge requiring active management. Third-party repricing companies have altered the reimbursement landscape, creating drastically reduced payments for providers and unexpected expenses for patients, and that landscape is now under direct legal challenge from APTA and other provider organizations.

• You're not obligated to accept repriced payments - No contractual relationship exists between providers and repricing companies, so you can challenge drastically reduced rates.

• Repricing entities profit from underpaying you - Claritev charges insurers roughly 5% to 7% of the difference between the billed and repriced amount, creating a direct financial incentive to minimize your payments.

• The No Surprises Act mostly doesn't apply to elective out-of-network PT visits - Its IDR process covers emergency care, in-network facility ancillary care, and air ambulance services, not routine outpatient therapy at a freestanding out-of-network clinic.

• The legality of repricing is actively being litigated - APTA joined federal antitrust litigation against Claritev and major insurers in October 2025, and a California appellate court revived related claims in September 2026.

• Thorough documentation is your strongest defense - Detailed clinical records justify your charges and help challenge unfair payment reductions from repricing companies.

Frequently Asked Questions

What is out-of-network physical therapy repricing?

Out-of-network repricing is when a third party, most commonly MultiPlan, now rebranded as Claritev, determines the payment amount an insurer sends to a physical therapy provider for out-of-network services, typically well below the original billed rate. There's no contract between the provider and the repricing company.

Is MultiPlan the same company as Claritev?

Yes. MultiPlan rebranded to Claritev in 2025 and continues operating the same out-of-network claim repricing business, serving more than 700 insurers, including all 15 of the largest US health plans.

Does the No Surprises Act protect out-of-network PT claims from repricing?

Only in specific situations: emergency services, out-of-network nonemergency services provided at an in-network facility, and air ambulance services. A patient who electively chooses an out-of-network PT clinic for routine outpatient care is generally not covered by the NSA's protections or its federal IDR process.

Are physical therapists obligated to accept a repriced payment?

No. Since there's no contractual relationship between the provider and the repricing company, providers can appeal or challenge a repriced payment through the payer's standard process. This isn't legal advice; providers with significant repricing losses should consult their own counsel or APTA's resources.

Is out-of-network repricing currently under legal challenge?

Yes. APTA and APTA Private Practice joined federal antitrust litigation against Claritev and major insurers in October 2025, and a California appellate court revived related claims in September 2026, ruling that insurer reimbursements are prices subject to antitrust law. The litigation is ongoing and unresolved.

How much of the billed amount does a repricing company keep?

Litigation records report Claritev charges insurers roughly 5% to 7% of the difference between the original billed charge and the repriced amount as its fee, giving both the insurer and the repricer a financial incentive to set the repriced amount as low as possible.

How can a PT clinic protect its revenue from out-of-network repricing?

The most effective steps are verifying out-of-network benefits before the visit, tracking repriced versus billed amounts by payer to spot patterns, giving patients transparent upfront cost estimates, and maintaining thorough clinical documentation to support appeals.