Quick Summary
- PHI Health LLC alleges Anthem and health plans it administers owe approximately $30 million in unpaid IDR awards
- The complaint involves more than 1,200 final payment determinations
- PHI is also seeking more than $1.3 million in interest
- Anthem disputes PHI’s characterization of the awards
- The lawsuit highlights continued uncertainty over enforcement of No Surprises Act IDR determinations
PHI Health Files Suit Over Unpaid IDR Awards
A new lawsuit is raising questions about what happens after a healthcare provider wins a payment determination through the federal Independent Dispute Resolution process.
PHI Health LLC, an air ambulance provider, filed a complaint against Anthem Insurance Companies and numerous health plans on August 31 in the U.S. District Court for the Southern District of Indiana. PHI alleges the defendants owe approximately $30 million under final IDR determinations issued through the No Surprises Act process.
According to the complaint, more than 1,200 determinations allegedly remain unpaid or underpaid. PHI is also seeking more than $1.3 million in interest.
Anthem disputes PHI’s characterization of the awards and has said it intends to defend against the claims.
How the Federal IDR Process Works
The No Surprises Act protects patients from many unexpected medical bills involving certain out-of-network services, including qualifying air ambulance transportation.
When a provider and payer cannot agree on reimbursement, either side may initiate the federal IDR process. Each party submits a proposed payment amount, and a certified IDR entity selects one of the offers after reviewing the permitted information.
The resulting determination is generally binding, and additional amounts owed typically must be paid within 30 days.
PHI alleges that Anthem allowed months to pass without fully paying certain awards.
PHI Alleges Delayed and Incomplete Payments
PHI claims Anthem used delayed payments, underpayments, and nonpayments to avoid fully satisfying final IDR determinations.
The provider also alleges these practices can pressure out-of-network providers to accept lower reimbursement or enter network agreements at rates below what they would otherwise accept.
These remain allegations. Anthem has stated that the federal IDR process includes eligibility requirements all parties are expected to follow and has voiced support for reforms focused on dispute eligibility.
Can Providers Enforce IDR Awards in Court?
The lawsuit also highlights a broader legal issue: whether providers can sue to enforce unpaid IDR determinations.
Courts have reached different conclusions. Some have found that the No Surprises Act does not create a private right of action to enforce an award, while others have allowed narrower enforcement claims to proceed.
That disagreement leaves providers with uncertainty when a final IDR determination is issued, but payment does not follow.
What This Means for Healthcare Providers
For healthcare providers using federal IDR, a favorable determination may not always be the end of the reimbursement process.
Providers should closely track payment deadlines, document outstanding balances, preserve payer communications, and maintain records of all IDR determinations and follow-up efforts.
As litigation continues, providers should also monitor developments that may affect available enforcement options.
How Patriot Group Can Help
Patriot Group helps healthcare providers navigate the federal IDR process, challenge inadequate reimbursement, manage payer disputes, and pursue revenue recovery opportunities.
If your organization is dealing with unpaid or underpaid out-of-network claims, delayed IDR payments, or other reimbursement issues, our team is available to help.
