Missouri Lawsuit Raises New Questions About Elevance Health’s Alleged Nonpayment of Binding No Surprises Act Awards and ERISA Fiduciary Oversight
LITIGATION UPDATE
No Surprises Act Enforcement | ERISA Fiduciary Liability
Complaint alleges that Elevance affiliates failed to timely satisfy binding federal arbitration determinations issued under the No Surprises Act and that employer-sponsored health plans and their fiduciaries failed to adequately monitor compliance with those obligations.
PHI Health, LLC has filed suit in federal court against Elevance Health affiliates Healthy Alliance Life Insurance Company and RightCHOICE Managed Care, Inc., which operate as Anthem Blue Cross and Blue Shield across most of Missouri, together with a number of self-funded employer-sponsored health plans and the plan fiduciaries responsible for overseeing them. The complaint seeks recovery on a more than a dozen separates, binding arbitration determinations issued under the No Surprises Act’s federal Independent Dispute Resolution (“IDR”) process, that together total approximately $333,000 in principle, plus interest and other relief.
The self-funded plans are named because, under the No Surprises Act, a self-funded plan is ultimately responsible for satisfying a binding IDR determination arising from the treatment of its beneficiaries.[1] PHI also alleges that affected plans and their fiduciaries failed to ensure that Elevance, acting as claims administrator, complied with the No Surprises Act, including by failing to monitor Elevance and to take corrective action.
The Missouri filing follows a related action PHI filed against Elevance affiliates in Kentucky, seeking approximately $2.1 million on a separate set of allegedly unpaid determinations. PHI alleges that the Kentucky and Missouri matters reflect the same underlying practice, repeated at scale: more than 1,200 binding IDR determinations, worth an estimated $30 million in the aggregate, that Elevance and its subsidiaries allegedly have failed to pay to PHI Health in full or on time across multiple states.
| SUMMARY OF THE MISSOURI FILING |
| Missouri claim ~ $333,000 across multiple allegedly unpaid IDR determinations, plus interest and other relief |
| Related Kentucky action ~ $2.1M across multiple allegedly unpaid IDR determinations, plus interest and other relief |
| Nationwide allegations 1,200+ IDR determinations valued at approximately $30 million that PHI alleges remain unpaid more than 30 days after issuance |
| Named defendants (Missouri) Healthy Alliance Life Insurance Company and RightCHOICE Managed Care, Inc. (Anthem Blue Cross and Blue Shield in Missouri); self-funded employer-sponsored plans and their fiduciaries, named as the parties statutorily responsible for payment |
| Central allegation against Elevance Failure to timely remit payment on binding IDR determinations, including determinations arising from claims administered on behalf of self-funded health plans |
| Core legal theories Violation the NSA’s mandatory payment obligation; Breach of ERISA fiduciary duties of prudence and monitoring |
The Federal IDR Framework
Congress enacted the No Surprises Act to remove patients from billing disputes between out-of-network providers and health plans, and to route those disputes instead through a federal arbitration mechanism. Under that framework, a certified IDR entity reviews the offers submitted by the provider and the plan or issuer and selects the appropriate payment amount. The resulting determination is binding on the parties, and federal law requires payment of the additional amount owed within 30 days of the determination, absent a timely challenge on the narrow grounds permitted by statute. For a self-funded employer-sponsored plan, the plan itself — rather than the third-party administrator that processes claim on its behalf — is generally the party ultimately responsible under the statute for satisfying a binding determination arising from its claims.[2]
| 1 Emergency service rendered | 2 Open-negotiation period | 3 Federal IDR proceeding | 4 Binding determination issued | 5 Payment due within 30 days |
Did Affected Plans and Fiduciaries Know the Awards Were Unpaid?
PHI alleges that Elevance affiliates processed the underlying claims, participated in the IDR proceedings on the plans’ behalf and/or submitted a competing offer during arbitration, lost, and still failed to cause payment to be issued within the statutory 30-day period and, in fact, for these claims, at all. According to the complaint, the oldest unpaid determination relates to a transport dating back to May 2022.
The complaint raises important questions, including:
- What, if any, independent oversight mechanisms were in place to identify the alleged systemic pattern of nonpayment by Elevance in contravention of the NSA’s mandatory payment obligation?
- What, if any, steps did the plans and their fiduciaries take to address noncompliance with the NSA?
PHI contends that the Missouri allegations are not isolated but instead reflect a broader nationwide pattern of Elevance non-compliance with the No Surprises Act.
Why Employer Health Plans Are Named as Defendants
Because the No Surprises Act imposes a payment obligation on the applicable health plan or insurer, PHI’s avenue for recovering the amounts allegedly owed runs through the plans themselves. The plans and their fiduciaries are named both as the parties from whom payment is sought under the statute and, separately, as defendants on ERISA claims addressed below.
ERISA Fiduciary-Duty Allegations
Apart from the payment claims, the complaint raises a distinct set of allegations against the plan fiduciaries. ERISA requires fiduciaries to act prudently and solely in the interest of participants and beneficiaries, obligations that include ongoing monitoring of third-party administrators such as Elevance. PHI alleges that, regardless of whether Elevance affirmatively disclosed the specific payment failures to the plans, a substantial and growing body of information independently placed fiduciaries on notice of a broader potential non-compliance concern with Elevance’s claims administration and required prudent investigation.
Alleged sources of notice to plan fiduciaries
The complaint identifies several categories of information that PHI alleges were available to the named fiduciaries, independent of any affirmative disclosure by Elevance, before the filing of this action, including:
- More than twenty lawsuits filed by other providers since 2024 seeking enforcement of unpaid IDR determinations;
- Regulatory guidance and statutory provisions addressing the obligation to timely pay binding determinations;[3]
- Judicial decisions recognizing the binding and enforceable nature of IDR awards;[4] and
- A growing body of public reporting alleging Elevance’s non-payment of binding IDR determinations.[5]
PHI alleges that these sources, considered together, provided sufficient notice to require a prudent fiduciary to investigate, monitor, and address Elevance’s administration of No Surprises Act claims on the plan’s behalf, regardless of whether Elevance itself disclosed the specific unpaid determinations. The Missouri complaint therefore raises a threshold question that extends beyond the parties to this case: if a third-party administrator allegedly fails to satisfy binding federal payment obligations, what systems should prudent fiduciaries have in place to identify that problem independent of the administrator’s own reporting? And were those systems present here? The complaint alleges that, whatever systems may have existed, they were insufficient to identify and address the alleged nonpayment practice.
Why This Lawsuit Matters in Missouri
PHI’s Missouri operations provide critical air medical transportation services for patients requiring specialized and time-sensitive care throughout the state. These transports help connect critically ill and injured patients with advanced healthcare resources at major medical centers, advanced pediatric facilities, including SSM Health Cardinal Glennon Children’s Hospital, as well as providing rapid response to emergency calls and interfacility transfers across Missouri. These missions can be lifesaving when specialized neonatal and pediatric critical care, trauma, cardiac, neurological, or other advanced pediatric medical care is needed. Hospitals and healthcare providers such as Hannibal Regional Medical Center and Good Samaritan Hospital in Mt. Vernon rely on access to air medical transportation when critically ill or injured patients require rapid transport to higher levels of care. PHI also transports pediatric and neonatal patients requiring advanced specialty care that may not be available in their local communities.
For many Missouri communities, particularly in rural areas, air medical transportation helps ensure that access to lifesaving specialty care is determined by a patient’s medical needs rather than where they live. However, sustained nonpayment for emergency services places increasing pressure on providers responsible for maintaining these critical healthcare resources across the state. If insurers can unilaterally disregard binding federal payment determinations and withhold payment for Missouri emergency services without consequence, they threaten the very fabric of the healthcare infrastructure that connects critically ill newborns, injured children, stroke victims, cardiac patients, and other Missourians experiencing medical emergencies to specialized care when every minute matters.
Legal and Policy Significance
The Missouri complaint raises questions with implications beyond the parties to this action, and beyond the State of Missouri. First, it asks whether a claims administrator can participate in a federal arbitration proceeding, lose, and fail to cause payment to be issued from plan assets. Second, it highlights a structural feature of the statute: because payment responsibility generally runs to the self-funded plan, a provider seeking payment may pursue the plan even where the administrator’s conduct causes the nonpayment. Third, it advances an ERISA oversight theory that does not depend on what the administrator reports. PHI alleges that available information, including provider demands, public litigation, judicial decisions, and reporting concerning alleged nonpayment, independently required fiduciaries to investigate. The plan’s liability may spring from an alleged failure to adequately oversee a third-party administrator that allegedly has adopted a nationwide pattern or practice of non-payment of binding federal IDR determinations contrary to the NSA’s mandatory payment obligation.
The litigation may prompt employer-sponsored health plans and their counsel to consider whether reliance solely on administrator reporting is sufficient when evaluating compliance with No Surprises Act payment obligations.
As additional lawsuits, judicial decisions, provider notices, and public reporting continue to emerge, the issue may attract increasing attention not only from courts and fiduciaries, but also from policymakers and regulators evaluating compliance with federal payment obligations.
Elevance, the self-funded employer-sponsored health plans, and the fiduciaries named as defendants have not yet responded to the Missouri complaint. The allegations described above remain subject to judicial determination and have not been proven.
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[1] The No Surprises Act imposes the applicable payment obligation to the “group health plan or health insurance issuer.” See 29 U.S.C. 1185f(a)(3)(B). In the case of a self-funded employer-sponsored health plan, PHI alleges that the plan itself is the party ultimately responsible for satisfying binding IDR determinations arising from its claims, even where claims administration functions are delegated to a third-party administrator.
[2] See note 1 supra.
[3] 29 U.S.C. § 1185e(c)(5)-(6); 29 U.S.C. § 1185f(b)(5)-(6); 29 C.F.R. §§ 2590.716-8, 2590.717-1.
[4] New England PA, LLC v. Cigna Health & Life Insurance Co., No. 3:25-cv-01472-JCH (D. Conn. July 21, 2026); Northeast Plastic Surgery Center, LLC v. Cigna Health & Life Insurance Co., No. 3:25-cv-01476-JCH (D. Conn. July 21, 2026); Shareef Jandali Plastic Surgery, LLC v. Cigna Health & Life Insurance Co., No. 3:25-cv-01367-JCH (D. Conn. July 21, 2026); Shareef Jandali Plastic Surgery, LLC v. Cigna Health & Life Insurance Co., No. 3:25-cv-01168-JCH (D. Conn. July 21, 2026); Agag v. Cigna Health & Life Insurance Co., No. 3:25-cv-00498-SRU, 2026 WL 1021213 (D. Conn. Apr. 15, 2026); PHI Health, LLC v. Optimum Choice, Inc., 826 F. Supp. 3d 654 (D. Md. 2026); Guardian Flight LLC v. Aetna Life Insurance Co., 789 F. Supp. 3d 214 (D. Conn. 2025); Guardian Flight, L.L.C. v. Health Care Service Corp., 140 F.4th 271 (5th Cir. 2025); GPS of New Jersey M.D., P.C. v. Horizon Blue Cross & Blue Shield, No. 22-6614, 2023 WL 5815821 (D.N.J. Sept. 8, 2023)
[5] See, e.g., Nick Hut, No Surprises Act IDR Enforcement Uncertain After Supreme Court Declines Review, HFMA (Jan. 14, 2026) (reporting public disputes concerning unpaid IDR awards and the availability of enforcement mechanisms); Anthem Sued for $2.1 Million in Unpaid NSA Arbitration Awards, Minevich Law Group (May 23, 2026) (reporting lawsuits alleging Anthem failed to timely satisfy numerous binding IDR determinations and describing the alleged nonpayment as a pattern rather than isolated claim-processing errors); Lawsuit Alleges Widespread Elevance Health Nonpayment of Binding Federal Arbitration Awards in Violation of the No Surprises Act; Claims Plan Fiduciaries Failed to Oversee Compliance, The Zoppoth Law Firm (Aug. 2026) (reporting PHI’s allegations that Elevance-affiliated entities failed to timely satisfy binding IDR awards and that plan fiduciaries failed to adequately oversee compliance with federal payment obligations).