Health insurer Anthem targeted in lawsuit over air ambulance claims

An air ambulance company is suing Anthem Blue Cross and Blue Shield, accusing the health insurer of sitting on about $30 million in unpaid claims approved by an independent arbitrator.

PHI Health LLC says the Indianapolis-based insurer is ignoring claims awards that are supposed to be binding under the federal No Surprises Act.

It says Anthem has either failed or refused to pay more than 1,200 final determinations, according to a lawsuit filed Monday in U.S. District Court for the Southern District of Indiana.

The delays and payment refusals allow Anthem and the plans it administers to cut their own costs and earn interest or investment income “on millions upon millions of dollars that were not timely paid,” PHI said in its complaint.

The No Surprises Act calls for an arbitrator to resolve payment disputes between insurers or bill payers and care providers outside the insurer’s network. This is done through an independent dispute resolution process.

The private arbitrator issues a written determination on the claim and selects an amount due to the care provider from the insurer. The federal law notes that these determinations are supposed to be binding, with payments made no later than 30 days after the determination, the PHI complaint states.

But the company says Anthem often lets months lapse without paying after a determination has been made.

“Without judicial enforcement, these ‘binding’ awards would be rendered meaningless to providers, and Defendants could ignore their statutory payment obligation,” the lawsuit states.

The lawsuit names Anthem and several companies the insurer works with to administer benefits.

A spokesman for Anthem’s parent, Indianapolis-based Elevance Health Inc., said the federal dispute resolution process “has clear eligibility requirements that all parties are expected to follow.”

“We will continue to defend against these actions while supporting reforms that strengthen eligibility standards and ensure (independent dispute resolution) remains focused on resolving appropriate out-of-network disputes,” spokesman Buddy Castellano said in an email.

The publicly traded Elevance is one of the nation’s largest health insurers. Its companies provided or administered coverage for 45 million people last year, and the parent brought in nearly $200 billion in total revenue.

Tempe, Arizona-based PHI says, aside from not paying, Anthem also has encouraged its clients to disregard their payment obligations.

PHI also says in its complaint that Anthem uses underpayments, no payments or delays to push companies like PHI into network agreements at below-market rates or take “arbitrarily low” payments for out-of-network care to avoid the dispute resolution process.

The plaintiff is asking the court to enforce the determinations under the No Surprises Act. It also wants more than $1.3 million in pre- and post-judgement interest.