Reporting and legal analysis on payer disputes, insurer lawsuits, and out-of-network reimbursement fights affecting healthcare providers.
September 24, 2026
The California Department of Managed Health Care has fined Blue Shield of California $800,000 after finding repeated failures to provide timely and complete information needed to investigate member complaints and appeals.
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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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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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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 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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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 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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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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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 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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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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