SpecialtyCare sues Anthem over $2.5 million in unpaid awards

SpecialtyCare Inc. and two affiliated physician groups are suing two Anthem health plans in Virginia, alleging the insurers failed to pay roughly $2.5 million owed under federal decisions resolving out-of-network medical payment disputes.

The lawsuit, filed Oct. 16 in the U.S. District Court for the Eastern District of Virginia, names Anthem Health Plans of Virginia Inc. and HealthKeepers Inc. as defendants. The plaintiffs are SpecialtyCare, Remote Neuromonitoring Physicians PC and Sentient Physicians PC.

According to the complaint, the providers obtained 1,443 awards through the No Surprises Act's independent dispute resolution process. The awards totaled about $2.75 million, but only about $249,800 had been paid as of Oct. 15, leaving approximately $2.5 million outstanding.

Anthem said it will defend against the lawsuit and supports reforms to the federal dispute resolution system.

"The federal IDR process has clear eligibility requirements that all parties are expected to follow," the company said. "We will continue to defend against these actions while supporting reforms that strengthen eligibility standards and ensure IDR remains focused on resolving appropriate out-of-network disputes."

The lawsuit alleges the unpaid awards span decisions issued between November 2022 and October 2026. SpecialtyCare says the statutory payment deadlines had expired for all of the disputed amounts.

Dispute centers on No Surprises Act payments

The No Surprises Act protects patients from certain unexpected out-of-network medical bills and establishes a process for providers and insurers to resolve payment disputes over covered services.

When negotiations fail, either party may initiate the law's independent dispute resolution process. A certified dispute resolution entity reviews payment offers from both sides and selects one amount.

SpecialtyCare alleges Anthem participated in those proceedings and received binding payment determinations but failed to pay the full amounts awarded within the required timeframe.

The providers are not seeking to reopen the payment decisions themselves. Instead, they are asking the court to enforce the awards, enter judgment for the unpaid balance and award applicable interest.

Providers pursue multiple legal claims

SpecialtyCare and its affiliated physician groups provide intraoperative neuromonitoring services, which monitor a patient's nervous system during surgery.

The providers say they performed services for patients covered by Anthem-issued or Anthem-administered health plans.

The lawsuit includes claims seeking to confirm and enforce the payment awards under both the No Surprises Act and the Federal Arbitration Act. It also includes claims under the Employee Retirement Income Security Act involving certain employer-sponsored health plans.

For those ERISA-related claims, SpecialtyCare argues it is entitled to payment either as a beneficiary under the statute or through assignments of patients' benefit rights.

The plaintiffs also allege Anthem may have breached fiduciary obligations in connection with some claims, depending on the role it performed for the health plans involved.

The legal path for enforcing No Surprises Act awards remains the subject of ongoing litigation in federal courts. SpecialtyCare cites rulings that have permitted providers to pursue enforcement actions while acknowledging that other courts have reached different conclusions.

The filing also points to related issues currently pending before several federal appeals courts.

The plaintiffs are seeking payment of the outstanding balance, interest and attorneys' fees and costs where permitted under ERISA. They also seek equitable relief requiring compliance with ERISA payment obligations for applicable claims.

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Noah Lopez is editorial assistant for InsuranceNewsNet. Contact him at noah.lopez@innfeedback.com.