Legal, compliance, revenue cycle, and payer dispute insights for healthcare providers navigating a changing regulatory landscape.
August 19, 2026
The Fifth Circuit struck down key federal rules for calculating the Qualifying Payment Amount, potentially affecting provider reimbursement and IDR strategy.
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August 17, 2026
Healthcare providers are claiming a major victory after a federal appeals court ruled that health insurers cannot manipulate reimbursement calculations.
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July 15, 2026
New research from the Elevance Health Public Policy Institute examines how the federal Independent Dispute Resolution (IDR) process is affecting reimbursement for certain planned procedures. The study found providers prevailed in nearly 90%…
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July 8, 2026
Kansas has sued Aetna, alleging violations of the Kansas False Claims Act involving its administration of the State Employee Health Plan, including third-party repricing arrangements and cross-plan offsetting practices.
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June 24, 2026
Aetna has filed a federal lawsuit alleging a physician, his wife, and affiliated healthcare entities used out-of-network billing arrangements and the No Surprises Act IDR process to generate more than $50 million in excess reimbursements.
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June 15, 2026
Arizona Attorney General Kris Mayes has filed a lawsuit against MultiPlan and several major health insurers, alleging they participated in a coordinated system that reduced payments to doctors and hospitals for out-of-network care.
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June 8, 2026
Massachusetts Attorney General Andrea Campbell has filed a lawsuit against UnitedHealthcare, alleging that the insurer improperly secured more than $100 million in payments from MassHealth, the state’s Medicaid program.
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June 3, 2026
Healthcare providers utilizing the federal Independent Dispute Resolution (IDR) process under the No Surprises Act will soon see significant changes aimed at improving efficiency and reducing administrative burdens. On May 28, 2026, the Departments of Health and Human Services, Labor, and Treasury, along with CMS, finalized new rules that overhaul key aspects of the federal IDR process.
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June 1, 2026
Industry experts say changes could save specialty practices thousands of dollars while speeding resolution of out-of-network payment disputes
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May 27, 2026
The Centers for Medicare & Medicaid Services (CMS) recently released an updated version of the Advance Beneficiary Notice of Non-Coverage (ABN), Form CMS-R-131. Providers and suppliers participating in fee-for-service Medicare are required to begin using the updated form no later than May 12, 2026.
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May 20, 2026
The California Hospital Association (CHA) has filed a lawsuit against Anthem Blue Cross over a policy that penalizes hospitals when patients receive care from out-of-network physicians at in-network facilities. The policy, which Anthem began expanding into California in 2026, imposes a 10% reduction in reimbursement for hospital claims involving certain out-of-network providers, including radiologists and physicians participating in scheduled procedures.
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May 4, 2026
A new piece of federal legislation is bringing renewed attention to health insurance claim denials and their impact on patients. The proposed Patient Refunds for Bad Denials Act, introduced by members of the U.S. House of Representatives, is designed to hold insurers accountable for high denial rates and increase transparency across the claims process.
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April 22, 2026
A newly announced policy from Anthem Health Plans is drawing criticism from the American Hospital Association and other industry stakeholders. Set to take effect in 2026, the policy would allow Anthem to penalize hospitals when out-of-network providers are involved in a patient’s care, even in situations where hospitals do not directly control those providers.
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April 1, 2026
Federal agencies are advancing updates to the Independent Dispute Resolution process. The Proposed Federal IDR Operations Rule is under review by the Office of Management and Budget, signaling that final regulations may be issued soon.
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March 18, 2026
Aetna has agreed to pay $117.7 million to resolve allegations that it improperly inflated payments received through the Medicare Advantage program. The settlement, announced by the U.S. Department of Justice, resolves claims that the insurer violated the federal False Claims Act by submitting or failing to withdraw inaccurate diagnosis codes tied to beneficiaries enrolled in its Medicare Advantage plans.
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March 10, 2026
The California Department of Managed Health Care (DMHC) recently announced two major enforcement actions against Health Net of California, Inc. and Anthem Blue Cross. Although the penalties were issued against insurers, the findings have important implications for healthcare providers navigating payment disputes, reimbursement delays, and patient grievance processes.
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January 30, 2026
The U.S. Department of Justice announced a historic $6.8 billion in recoveries under the False Claims Act (FCA) for fiscal year 2025, marking one of the largest enforcement years in the statute’s history. Healthcare-related matters once again dominated recoveries, underscoring the federal government’s continued focus on billing accuracy, reimbursement compliance, and fraud prevention across public and private payor programs.
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January 6, 2026
In the case of Everett v. UMR, Inc., a federal district court judge recently ruled in favor of an out-of-network doctor who sued an insurance administrator for failing to pay out insurance benefits owed to him under the Employee Retirement Income Security Act (ERISA). As part of its decision, the court rejected the argument that the doctor had an obligation to hold the patient responsible for unpaid portions of the disputed medical expenses.
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January 5, 2026
In a lawsuit filed on December 8, 2025, in the U.S. District Court of Connecticut, a group of 33 NorthStar anesthesia providers alleged that Aetna and Cigna failed to comply with binding IDR decisions under the No Surprises Act. The complaint asserts that the two insurers owe more than $4.1 million in total — approximately $2.3 million from Cigna and $1.7 million from Aetna — for services already adjudicated through the federal arbitration process.
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December 8, 2025
After more than 10 years of litigation, American Clinical Solutions (ACS) secured a $3.1 million verdict in a billing dispute against Triple-S Salud, an independent licensee of the Blue Cross Blue Shield Association and a subsidiary of GuideWell. The Florida jury’s decision may set the stage for future victories by providers seeking unpaid claims.
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November 24, 2025
New Jersey Attorney General Matthew Platkin announced a $100 million settlement resolving claims that Horizon Blue Cross Blue Shield misled the state to secure a contract administering health plans covering more than 750,000 public employees, retirees, and dependents.
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November 6, 2025
Anthem Blue Cross and Blue Shield (a unit of Elevance Health) has introduced a policy that could significantly impact how in-network hospitals work with out-of-network physicians. Starting January 1, 2026, Anthem will impose a 10% administrative penalty on the allowed amount for any claim involving out-of-network providers—unless the care qualifies as emergency or has been pre-approved.
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October 29, 2025
In Bolton v. Inland Fresh Seafood Corp. of America, Inc., the Eleventh Circuit reaffirmed its strict requirement that ERISA plaintiffs must exhaust a plan’s internal claims process before pursuing litigation—even in cases alleging fiduciary breach.
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September 8, 2025
UnitedHealthcare, the largest health insurer in the country, filed a lawsuit in August 2025 against Radiology Partners, the nation’s largest radiology group, accusing the provider of manipulating the Independent Dispute Resolution (IDR) process under the No Surprises Act. The suit, filed in federal court in Arizona, claims Radiology Partners used a separate out-of-network entity—Sonoran Radiology—to submit claims for services actually performed by in-network physicians, allegedly to generate higher reimbursements through arbitration.
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August 12, 2025
The American College of Radiology (ACR), along with the American College of Emergency Physicians (ACEP) and the American Society of Anesthesiologists (ASA), is backing new legislation aimed at holding insurers accountable when they delay payments following Independent Dispute Resolution (IDR) decisions. The bill would strengthen the enforcement of the No Surprises Act by ensuring providers are paid promptly after winning arbitration.
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July 15, 2025
In June 2025, the Department of Justice (DOJ) announced the largest healthcare fraud enforcement action in U.S. history, charging 324 individuals in schemes totaling over $14.6 billion in intended losses. Known as “Operation Gold Rush,” the nationwide sweep included doctors, medical executives, and billing companies accused of exploiting federal and private healthcare programs.
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July 14, 2025
$31.5M DOJ Settlement: Fresno Community Hospital and Physicians Network Advantage paid to resolve allegations of violating the Anti-Kickback Statute and Stark Law through improper EHR-related incentives.
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June 18, 2025
Starting January 1, 2026, healthcare providers in Florida will be legally required to refund patient overpayments within 30 days of identification. Under the new Florida law, this applies to any licensed facility or practitioner that submits claims to government or private insurers. Providers should begin reviewing and updating their billing and refund protocols well ahead of the deadline.
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June 17, 2025
Two new lawsuits from Elevance Health subsidiaries are raising significant questions about how providers are using the No Surprises Act’s Independent Dispute Resolution (IDR) process. The cases, filed by Anthem Blue Cross and Blue Shield of Ohio and Blue Cross Blue Shield Healthcare Plan of Georgia, accuse healthcare providers and billing company HaloMD of submitting large volumes of ineligible claims through IDR to boost reimbursements and drive up arbitration costs.
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June 16, 2025
A recent letter from the ERISA Industry Committee (ERIC) urges the IRS to revise the No Surprises Act’s (NSA) dispute resolution framework, claiming it places too much financial pressure on employer-sponsored health plans. According to ERIC, out-of-network providers are winning the majority of arbitration cases and receiving payments significantly higher than in-network rates.
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May 22, 2025
UnitedHealth Group Inc. is facing mounting scrutiny following a report that the company is the subject of a criminal investigation into its Medicare Advantage billing practices. According to a recent article from BenefitsPRO, the U.S. Department of Justice has been conducting the probe since at least mid-2024. Although UnitedHealth stated it has not been formally notified, the news triggered an 18% drop in the company’s stock, adding to a tumultuous week that included the sudden replacement of its CEO and the suspension of 2025 guidance.
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April 16, 2025
Several major health insurers and Zelis Healthcare LLC, a third-party health cost management company, are now defendants in multiple class action lawsuits alleging a conspiracy to suppress payments to out-of-network healthcare providers. Filed in federal courts in California, Massachusetts, and Kansas, the suits claim that Zelis and insurers including Aetna, Cigna, Elevance Health, and Humana coordinated efforts to reduce reimbursement rates, raising significant antitrust concerns.
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April 8, 2025
Recent reporting by The Wall Street Journal highlights a significant issue affecting state Medicaid programs: duplicate payments made to insurers due to beneficiaries being enrolled more than once. These billing errors have led to overpayments that, in some states, may amount to hundreds of millions of dollars. As states intensify efforts to audit and recover these funds, insurers and healthcare providers must be aware of the legal and compliance risks involved.
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April 7, 2025
A former global price risk manager for Mars Inc.'s Wrigley subsidiary, Paul R. Steed, has been indicted in federal court for allegedly embezzling over $28 million from the company. The indictment includes seven counts of wire fraud and two counts of tax evasion. Authorities say Steed allegedly used fake shell companies—MCNA LLC and Ibera LLC—to invoice Mars for services never rendered and reroute funds intended for the company into accounts he controlled.
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April 2, 2025
As recently reported in The Wall Street Journal, The Department of Justice announced it is conducting an investigation into Medicare Advantage billing practices of United Health Care (UHC).
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March 11, 2025
A 4-year investigation by the North Carolina Department of Insurance resulted in a very large fine against United Health Care related to its balance billing practices. The department found that UHC was not doing enough to protect members, who had Emergency Room care or Anesthesia, from balance billing by out of network providers.
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December 29, 2023
#### I wanted to provide summary of recent regulatory action of concern to the Healthcare Provider. This actual case can provide valuable guidance to the healthcare provider and assist their staff in creating policies and staff training to avoid these type of compliance issues.
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December 29, 2023
#### I wanted to provide weekly summaries of recent cases of concern to the Healthcare Provider. These actual cases and lawsuits can provide valuable guidance to the healthcare provider and assist their staff in creating policies and staff training to avoid these type of compliance issues. Our company defends these type of audit cases daily.
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June 29, 2023
Adding to the chaos underlying the implementation of the No Surprises Act (the “NSA”), on Thursday, December 9, 2021, the American Medical Association and the American Hospital Association, among others, filed suit in the U.S. District Court for the District of Columbia against the U.S. Depts. of Health and Human Services, of Labor, and of the Treasury, as well as the Office of Personnel Management (collectively, the “Departments”), requesting that the Court issue an injunction against certain aspects of the Interim Final Rule issued on September 30, 2021 (the “IFR”). See Case No. 1:21-cv-03231.
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June 29, 2023
Like many practices and providers, you may be of the belief that preauthorization will either guaranty payment for services rendered or, alternatively, should the carrier refuse to fairly compensate for such services, allow for a variety of legal claims to be brought in court. This belief, however, is often misguided as the U.S. District Court for the District of New Jersey just explained in Advanced Orthopedics & Sports Med. Inst., P.C. v. Oxford Health Ins., Inc. (Civil Action No. 21-17221).
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June 29, 2023
A chiropractor practicing in East Meadow pleaded guilty in federal court in Central Islip Monday to a $1 million healthcare fraud scheme, officials said.
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June 29, 2023
I have reviewed a few recent Plan Documents that contain the following wording, “The Covered Person is required to pay the out-of-pocket expenses including Deductbles, Co-pays, or required Plan Parlicipation) under the terms of this Plan. The requirement that You and Your Dependent(s) pay the applicable out-of-pocket expenses may not be waived by a provider under any "fee forgiveness,” "not out-of-pocket," or similar arrangement. If a provider waives the required out-of-pocket expenses, the Covered Person's calm mav be denied and the Covered Person will be responsible for payment of the entire claim. The claim(s) may be reconsidered if the Covered Person provides satisfactory proof that he or she paid the out-of-pocket expenses under the terms of this plan.”
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June 29, 2023
In the recently filed case of Popovchak, et al. v. UnitedHealth Group Inc., et al, the plaintiffs, as representatives of a proposed class, put forth significant allegations against various UnitedHealthcare affiliates/subsidiaries (collectively, “UHC”), detailing a scheme in which UHC has drastically enriched itself to the detriment of self-funded plan participants.
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June 29, 2023
In the case of Ecure Ind. Corp. v. United Healthcare Ins. Co., 2023 U.S. Dist. LEXIS 91562 (United States District Court for the Southern District of Indiana), Ecure, who purchased the receivables for the healthcare provider, brought suit against UnitedHealthcare (UHC) for quantum meruit/unjust and for agreed upon account stated. The agreed to account stated cause of action was dismissed but the unjust enrichment/Quantum Meruit argument survived dismissal. Under Indiana law, a plaintiff alleging unjust enrichment must show: (1) a benefit conferred upon another at the express or implied request of the other party; (2) allowing the other party to retain the benefit without restitution would be unjust; and (3) the plaintiff expected payment. The provider’s Complaint alleges that the Physicians conferred a benefit on United by providing emergency medical services to United's insureds; that the low allowance of their claims provided them with unjust restitution and, as such, the provider was entitled to payment. The Court agreed. We will follow this case and report any developments.
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