Notes · payer machinery
Who gets paid when your claim is cut? The repricing industry, in its own words
When a claim comes back paid far below what you billed — or below what your contract says — the number usually wasn't chosen by a person at your payer. It was computed by a vendor: a repricing or claims-editing company sitting between the payer and your remittance. Most practices have never heard these companies' names. But the vendors themselves have described, in regulatory filings and patents, exactly how they work and exactly how they're paid.
This note assembles that public record. Every claim below links to a primary source: an SEC filing, a granted US patent, or a court document.
The fee model: a percentage of the cut
MultiPlan is the largest independent claim-repricing company in the country. When it went public in 2020, its investor filings described the revenue model in plain terms: for most of its business, MultiPlan is paid a percentage of the "savings" it identifies — roughly 5 to 13 cents of every dollar by which a claim is reduced. In 2019, that model produced about $983 million of revenue against roughly $19 billion in claimed customer savings, at margins the filings put around 76% of revenue (adjusted EBITDA). The filings are on EDGAR.
Why this matters to your billing office: the vendor that computes what your claim is "worth" earns more when the answer is lower. That's not an accusation — it's the disclosed business model. It simply means a repriced amount on your remittance is a starting position, not an objective market figure, and it's reasonable to verify it like one.
The model isn't unique to repricing. Cotiviti — a payment-integrity vendor that works post-payment — described a similar percentage-of-recovery structure in its 2016 annual report, which reported about $3.3 billion in "savings identified" for clients that year.
The math is patented — and readable
How does a repricer decide what an out-of-network claim should pay? For MultiPlan's Data iSight product, the methodology is described in US Patent 8,103,522, "System and method for calculating claim reimbursement recommendations." In the patent's own description: outpatient claims are benchmarked against a group of comparable providers' billed charges per procedure code, arranged into deciles, and reimbursed at a chosen percentile of that distribution, adjusted by a proprietary charge index. Professional claims are recommended at the median accepted reimbursement.
Two things follow from reading the patent. First, the "recommended payment" on a repriced claim is the output of a percentile choice — a dial, not a law of nature. Second, because the methodology is published, a practice disputing a repriced amount can ask precise questions: what benchmark group, what percentile, what data source, what date range. Vague answers to precise questions are themselves informative.
The scale of the editing layer
Repricing is one layer. The other is claims editing — the software that bundles, downcodes, and reduces claims at adjudication. Change Healthcare's annual report for fiscal 2020 stated that payers using its primary claims-editing product realized on the order of $12 billion per year in savings, and that its out-of-network management services saved payers an average of 36% on out-of-network claims. Optum's public product literature for its Claims Edit System quotes savings to payers of roughly $36 to $82 per member per year, depending on configuration.
Multiply the per-member figure by a large plan's membership and you get the size of the pool: the editing layer removes tens of billions of dollars a year from provider payments, across all payers, before anyone looks at an individual claim. Some of those edits are correct applications of coding rules. Some are not. The American Medical Association's National Health Insurer Report Card — the last public payer-by-payer audit of this behavior, discontinued in 2013 — found payers' edit rates on claim lines varied by roughly 18-fold, and that payers reported the correct contracted fee-schedule amount only 62–87% of the time, depending on the payer.
What happened when it went to trial
In 2021, a group of Nevada emergency physician groups (affiliated with TeamHealth) took UnitedHealthcare to trial over systematically reduced out-of-network emergency claims. The jury found for the physicians and awarded $60 million in punitive damages on top of compensatory damages. In 2025, the Nevada Supreme Court affirmed the compensatory award on an unjust-enrichment theory and reduced the punitive award to a 1:1 ratio — and, in a separate 2025 ruling, declined to seal the internal documents that had been admitted at trial. The trial record, including the payer-side documents describing how out-of-network emergency claims were repriced, is public.
Meanwhile, a consolidated federal antitrust case — In re MultiPlan Health Insurance Provider Litigation (MDL 3121, N.D. Ill.) — alleges that MultiPlan's repricing tools functioned as a mechanism for competing insurers to align out-of-network payments. Those are allegations, not findings; the case is in active litigation. But in June 2025 the court allowed the core antitrust claims to proceed, and the US Department of Justice filed a statement of interest addressing the legal theory. The docket is worth watching regardless of outcome, because the filings describe the repricing mechanics in unusual detail.
What a Florida practice can do with this
- Treat a repriced amount as an offer, not a verdict. The number came out of a percentile-based model whose operator is paid on the reduction. It is negotiable and disputable, and the methodology is fair game to question.
- Use your disclosure rights. On out-of-network claims covered by the No Surprises Act, the plan must disclose the qualifying payment amount with the remittance, and — on request — how it was derived, including whether a third-party database was used. If a claim was downcoded, the plan must say so and identify what was changed.
- Check repriced claims against your contract. The quieter version of this problem is in-network: a contracted claim paid below the fee schedule, buried under a CO-45 adjustment. Florida gives you 12 months to claim an underpayment, with 12% interest — a clock most practices let expire.
- Don't accept "the vendor said so" as a reason. Under Florida's workers' comp rules, the carrier remains accountable for payment decisions regardless of any service company or TPA acting on its behalf. The same logic applies practically everywhere: your dispute is with the payer, and the payer owns the vendor's output.
Sources
MultiPlan / Churchill Capital Corp III merger filings (DEFA14A, 2020) and subsequent annual reports, via SEC EDGAR · US Patent 8,103,522 (claim reimbursement recommendations) · Change Healthcare Form 10-K (FY2020), via SEC EDGAR · Cotiviti Holdings Form 10-K (2016) · UnitedHealthcare Ins. Co. v. Fremont Emergency Services, Nevada Supreme Court No. 85656 (2025) · In re MultiPlan Health Insurance Provider Litigation, MDL 3121 (N.D. Ill.) · US DOJ Antitrust Division statement of interest (2024) · AMA National Health Insurer Report Card series (2008–2013). Figures retrieved August 2026; SEC figures are as reported for the periods stated in each filing.