Insights on Managed Care, Payer Disputes & Reimbursement

ArentFox Schiff’s Pat Naples discusses with Medical Economics the US Centers for Medicare & Medicaid Services’ (CMS) expanded anti‑fraud enforcement and its impact on health care providers.

On March 9, a federal court in Connecticut issued a decision in Abira Medical Laboratories LLC v. Aetna Inc. et al. that underscores the continuing importance of clear and comprehensive assignment-of-benefits language in payer disputes.

The past year has been unusually active on the health care antitrust front. Providers are pressing price-fixing and information-exchange theories against payers and claims intermediaries and a landmark class settlement moving into its implementation phase.

Generally, the Employee Retirement Income Security Act of 1974 (ERISA) prohibits discrimination based on a plan participant’s health status-related factor, such as a medical condition, medical history, or genetic information.

On August 18, the US Court of Appeals for the Federal Circuit issued a significant decision in King v. United States, affirming that reductions in multiemployer pension benefits authorized by the Multiemployer Pension Reform Act of 2014 (MPRA) are not takings under the Fifth Amendment.

Health Care Partner David Greenberg will present in a BARBRI CLE course titled “Overpayment Recoveries by Health Insurers: Bringing and Defending Claims, Evaluating Merits, Scope of Recovery” on October 1, 2025.

Following nearly two years of litigation, Cigna Health and Life Insurance Company and the named plaintiffs in Hecht v. Cigna Health and Life Insurance Co., Case No. 1:24-cv-05926 (N.D. Ill.) have announced a class action settlement in principle.

A North Carolina federal court’s recent order granting remand in the case Nash Hospitals, Inc. v. UnitedHealthcare of North Carolina, Inc., et al., No. 5:25-CV-28-FL underscores the limits of federal question jurisdiction in disputes arising from health care provider-payer agreements, particularly where the claims are grounded in state law and do not necessarily require resolution of a substantial federal issue.

Congress enacted the No Surprises Act (NSA) to protect patients from unexpected medical bills. A central pillar of the NSA is its independent dispute resolution (IDR) process, under which payers and providers can submit disputed claims to binding arbitration.

A recent decision from the US District Court for the Eastern District of New York has significant implications for providers navigating the No Surprises Act (NSA) independent dispute resolution (IDR) process.

On May 27, Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. (BCBSGA) filed a lawsuit in the Northern District of Georgia US District Court, alleging that a group of health care providers, along with their third-party billing agent, manipulated the federal No Surprises Act’s (NSA) independent dispute resolution (IDR) process.

Within the last month, the US District Court for the Northern District of California rejected efforts by United Behavioral Health (UBH) to dismiss and decertify two class actions seeking relief related to UBH’s processing of mental health claims.

A litigation before a court in one jurisdiction may require taking third-party discovery from third parties located in different jurisdictions. Litigants seeking third-party discovery from parties in other states may quickly discover that the process can be more complex than expected.

Anthem Inc. has agreed to settle a class action lawsuit brought by participants in employee health plans administered by the insurer.

Ambulatory surgery centers (ASCs) have become a large and growing part of the health care industry. ASCs offer same-day surgical care, including diagnostic and preventive procedures, and their popularity has recently grown.

The US District Court for the Eastern District of New York in Manalapan Surgery Ctr., et al. v. 1199 SEIU National Benefit Fund, No. 23-CV-03525 (EDNY March 12, 2025), recently granted a motion to dismiss a complaint filed by four out-of-network ambulatory surgery centers against 1199 SEIU National Benefit Fund.

A federal court recently rejected arguments by MultiPlan, Inc. and Cigna Health and Life Insurance Company that they had no obligation to ensure payments at the contractually negotiated, in-network rate to Anatomic and Clinical Laboratory Associates, P.C. (ACLA).

California is leading the way in ensuring that determinations of medically necessary health care services are made by licensed physicians and not artificial intelligence (AI) algorithms.

On September 9, the US Departments of Labor, Treasury, and Health and Human Services (the Departments) jointly released a final rule to ensure that group health plans comply with the Mental Health Parity and Addiction Equity Act (MHPAEA).

On August 2, health care providers scored yet another significant victory when the US Court of Appeals for the Fifth Circuit affirmed the vacatur of various federal regulations regarding the arbitration procedures used to resolve billing disputes between providers and insurers.

On July 19, the US District Court for the Northern District of Texas denied a motion to dismiss Blue Cross Blue Shield of Texas (BCBSTX), which claimed sovereign immunity in a suit brought by a group of providers.

In a recent opinion, Smith et al. v. UnitedHealth Group Inc. et al., the US Court of Appeals for the Eighth Circuit affirmed the dismissal of an Employee Retirement Income Security Act (ERISA) class action suit brought by health plan participants.

On April 23, the US Department of Labor (DOL) released a final rule significantly expanding the definition of who qualifies as a fiduciary under the Employee Retirement Income Security Act (ERISA) (the Retirement Security Rule or Final Rule).

Last week, the US Court of Appeals for the Fourth Circuit issued a decision holding that state health care plans in North Carolina and West Virginia must cover gender-affirming surgeries.

In a win for plaintiffs, the US Court of Appeals for the Ninth Circuit recently reversed a district court’s dismissal of key claims in the case of Ryan S. v. UnitedHealth Group, Inc.