Elevance Lawsuit: Georgia Providers & No Surprises Act
- Elevance, under its Anthem brand blue Cross Blue Shield Healthcare Plan of Georgia (BCBSGA), has filed a federal lawsuit against HaloMd, Hospitalist Medicine Physicians of Georgia, and Sound...
- The no Surprises Act, enacted in 2022, protects consumers from unexpected out-of-network medical bills.
- Elevance contends that the defendants falsely claimed disputes were eligible for IDR, failed to properly group similar claims, and initiated claims without observing required waiting periods.
Elevance Sues Georgia Providers Over No Surprises Act Gaming
Elevance, under its Anthem brand blue Cross Blue Shield Healthcare Plan of Georgia (BCBSGA), has filed a federal lawsuit against HaloMd, Hospitalist Medicine Physicians of Georgia, and Sound Physicians Emergency Medicine of Georgia.The suit, filed Tuesday, alleges the companies conspired to exploit the No Surprises Act’s independent dispute resolution (IDR) process to illicitly gain millions.
The no Surprises Act, enacted in 2022, protects consumers from unexpected out-of-network medical bills. It established the IDR process to resolve payment disputes between providers and insurers, with a third-party arbiter selecting a fair price. However, Elevance now claims these Georgia providers flooded the system with ineligible disputes to boost profits.
Elevance contends that the defendants falsely claimed disputes were eligible for IDR, failed to properly group similar claims, and initiated claims without observing required waiting periods. The lawsuit further alleges that almost 70% of disputes where the providers prevailed were clearly ineligible. The insurer also accuses the providers of concurrently filing a large number of disputes, overwhelming BCBSGA and inflating payout requests by as much as 900% above median contracted rates.
According to Elevance, these actions have cost the insurer $5.9 million in excess payments and IDR fees since the start of 2024. The lawsuit seeks to retroactively nullify the providers’ IDR awards and prevent the alleged scheme from continuing. The success of challenging IDR determinations remains uncertain, though Elevance argues an exception exists in cases of fraud.
“We are holding billing companies and out-of-network providers accountable for what we believe are fraudulent and abusive practices that result in excessive healthcare costs, burden consumers, and undermine the integrity of our healthcare system,” an Elevance spokesperson said. “We believe healthcare should be obvious,fair,accessible,and affordable. That’s why we support the intent of the No Surprises Act and why we are pursuing this lawsuit.”
Sound Physicians and Hospitalist Medicine have not yet commented on the allegations. The case highlights ongoing tensions between payers and providers regarding fair payment for out-of-network care and the integrity of the No surprises Act’s implementation.
What’s next
The court will now consider Elevance’s claims of fraud and abuse within the No Surprises Act’s IDR process, possibly setting a precedent for future challenges to arbitration awards and further scrutiny of billing practices.