Out-of-network coverage lawsuits are legal claims that challenge health insurance companies for misleading patients about their provider networks, underpaying out-of-network healthcare providers, or using deceptive practices to avoid paying for legitimate medical care. These lawsuits have exploded in recent years, particularly following enforcement of the No Surprises Act in 2022, as patients increasingly discover that their insurance company’s online provider directory includes doctors and facilities that either don’t participate in the network or no longer accept their insurance plan. In October 2025, Cigna paid $5.7 million to settle claims that it maintained “ghost networks”—lists of providers not actually available to members—which caused patients to receive surprise bills and suffer credit damage when they were billed directly.
The scope of this litigation has expanded dramatically to include not just patient suits but also lawsuits from healthcare providers, state medical associations, and federal agencies. Providers allege that major insurers like UnitedHealthcare, Aetna, Cigna, and others systematically use repricing software and underpayment schemes to reduce what they owe for out-of-network care. These cases involve billions of dollars in disputed payments and reveal a fragmented healthcare system where the promise of insurance coverage often diverges sharply from the reality patients and doctors experience.
Table of Contents
- What Are Ghost Networks and How Do They Harm Patients?
- How Insurance Companies Underpay Out-of-Network Providers
- Recent Major Settlements and What They Reveal
- Active Litigation: Who Is Suing and Why
- The No Surprises Act and Enforcement Challenges
- Repricing Software and Antitrust Concerns
- What’s Next for Out-of-Network Coverage Litigation
- Conclusion
What Are Ghost Networks and How Do They Harm Patients?
Ghost networks are inactive, incomplete, or outdated provider directories maintained by health insurance companies to make their networks appear larger and more accessible than they actually are. A patient might log into their insurance company’s website, see that their preferred specialist is listed as in-network, schedule an appointment, and only discover at the time of service that the doctor no longer participates, left the practice, or was listed incorrectly. The result is an unexpected out-of-network bill that can range from hundreds to tens of thousands of dollars, depending on the procedure.
The January 2026 Medicare Advantage ghost network lawsuit against EmblemHealth, filed on behalf of New York City employees, illustrates the problem graphically: one psychiatrist was listed 29 times in the provider directory to inflate the size of the mental health network. When patients tried to access these “redundant” listings, they discovered the same provider couldn’t see new patients or was listed at incorrect addresses and phone numbers. Similar litigation has been filed against Blue Shield of California and Cigna, with courts and regulators increasingly finding that these practices violate federal healthcare laws and state consumer protection statutes.
How Insurance Companies Underpay Out-of-Network Providers
Beyond ghost networks, the core dispute in many out-of-network coverage lawsuits centers on how much health plans actually pay providers for services rendered outside their networks. When a patient sees an out-of-network doctor, the insurer typically uses a repricing software tool or internal methodology to determine what they consider a “reasonable” charge. That determination directly affects how much the provider is reimbursed and, by extension, how much the patient is billed for the remainder. If the insurer’s “reasonable” determination is artificially low, the provider absorbs the loss or bills the patient, and the patient pays more than they would have with an in-network provider.
The Zelis Healthcare antitrust case, currently before a Massachusetts federal court, alleges that five major insurers—Aetna, Cigna, Elevance Health, Humana, and UnitedHealth Group—conspired to use Zelis repricing technology to systematically depress out-of-network reimbursement rates. Courts have rejected motions to dismiss, allowing the case to proceed. In a separate matter, the MultiPlan price-fixing litigation alleges that MultiPlan, a repricing intermediary, and affiliated health plans coordinated to underpay providers by approximately $19 billion annually. That case is actively in discovery with potential trial on the horizon. The limitation of these cases is that even if providers win, insurers can appeal, and the legal process often takes years to resolve.
Recent Major Settlements and What They Reveal
In October 2025, Cigna agreed to pay $5.7 million to resolve claims that its ghost networks misled members about provider availability and caused financial harm through surprise bills that damaged patients’ credit. Around the same time, UnitedHealthcare settled a separate case in North Carolina for $3.4 million, resolving allegations that it failed to pay adequate reimbursement rates for out-of-network medical services, leaving patients to absorb larger portions of their bills. While these settlements are significant, they are modest relative to the size of these companies and the scale of out-of-network billing in the U.S.
healthcare system, suggesting that class members may receive minimal individual payments. Both settlements required defendants to make injunctive promises: improving provider directories, strengthening verification processes, and establishing complaint procedures. However, complaints about outdated directories and inaccurate information continue to surface, indicating that even settled cases have not fully resolved the underlying problems. Patients considering joining these class actions should understand that settlement distributions can take months or years to process, and individual payments are typically capped by the size of the class and complexity of claim administration.
Active Litigation: Who Is Suing and Why
In January 2026, Delta Dental faced a class-action lawsuit alleging it systematically misrepresents its out-of-network dental coverage to patients, a complaint mirroring claims made against health insurers. The same month, new ghost network litigation was filed against EmblemHealth, Blue Shield of California, and Cigna on behalf of New York City employees and psychiatrists alleging provider directory fraud. These cases demonstrate that out-of-network coverage disputes are not limited to health insurance; dental and behavioral health insurers face similar allegations.
One significant wrinkle emerged in March 2026 when a federal judge dismissed Elevance Health subsidiary’s lawsuit against HaloMD, an independent dispute resolution (IDR) intermediary, for insufficient evidence of abuse. However, HaloMD continues to face similar lawsuits in Georgia, Ohio, and Texas. This mixed outcome shows that plaintiffs’ success varies depending on the specific facts and jurisdiction, and insurers may face uneven outcomes across different courts and different defendants.
The No Surprises Act and Enforcement Challenges
The No Surprises Act, which took effect in 2022, was designed to protect patients from surprise out-of-network bills by prohibiting providers from billing patients more than in-network cost-sharing amounts and requiring insurers to pay out-of-network claims at agreed rates or submit to independent dispute resolution. Yet the law has spawned at least nine formally tracked lawsuits filed by insurers against IDR intermediaries since December 2024, with new filings in January and February 2026 by UnitedHealthcare and the Health Care Service Corporation. These insurers argue that IDR intermediaries are abusing the process and issuing unfavorable decisions; the intermediaries counter that they are applying the law fairly and that insurers simply dislike paying higher rates.
The irony is that a law intended to protect patients has triggered a secondary round of litigation over its implementation. Patients should be aware that IDR disputes can still occur, and the outcome depends partly on which intermediary handles the case. Additionally, the No Surprises Act does not cover all types of insurance or all providers, so gaps remain in protection. For example, some state-regulated insurance products and certain providers may be exempt, leaving pockets of vulnerability.
Repricing Software and Antitrust Concerns
Beyond individual cases, a larger question underlies many out-of-network lawsuits: whether repricing software firms and health insurers have conspired to unlawfully suppress provider payment. The Erie County Medical Center case, filed in Chicago federal court, involves hundreds of healthcare providers in litigation against Claritev, a repricing software vendor, alleging it created an illegal price-fixing system benefiting health insurers at providers’ expense. A hearing is potentially scheduled for 2027.
Similarly, the Zelis Healthcare case and MultiPlan litigation raise antitrust concerns about whether the use of repricing intermediaries constitutes unlawful monopolistic behavior or price-fixing, questions that federal courts are still exploring. These antitrust cases carry significant implications because if courts find that repricing companies and insurers did collude, the damages could reach billions of dollars. However, antitrust litigation is notoriously complex and slow-moving, and defendants have strong incentives to appeal unfavorable rulings. Providers and patients should not expect rapid resolution, but continued legal pressure may ultimately force changes to how out-of-network reimbursements are calculated.
What’s Next for Out-of-Network Coverage Litigation
As of March 2026, Aetna was still defending itself after a federal judge rejected its motion to dismiss an out-of-network payment lawsuit, allowing litigation to proceed against the insurer. This decision suggests that courts are increasingly skeptical of insurers’ arguments that out-of-network practices comply with law.
More lawsuits are likely to be filed as attorneys and advocacy groups continue to investigate insurer practices and as the results of existing cases become public. Future litigation may also focus on newer practices, such as insurers’ use of reference-based pricing and narrow networks that deliberately exclude high-cost providers. As courts develop clearer standards for what constitutes fair out-of-network reimbursement and transparent provider directory maintenance, the legal landscape will become more defined, potentially opening new litigation opportunities or, conversely, prompting insurers to settle more cases proactively.
Conclusion
Out-of-network coverage lawsuits address a fundamental problem in American healthcare: the gap between insurance companies’ promises and their practices. Ghost networks mislead patients into believing they have access to providers they do not, while repricing schemes and underpayment practices shift financial risk from insurers to patients and providers. Recent settlements with Cigna and UnitedHealthcare have established liability and established monetary remedies, but the underlying problems persist, as evidenced by active litigation against insurers, repricing software companies, and IDR intermediaries.
If you have received a surprise out-of-network bill or discovered that a provider listed on your insurance company’s website is not actually available to you, you may have a claim in existing class actions or may be entitled to relief under the No Surprises Act. Consult with a healthcare attorney or class action administrator to determine whether you qualify for compensation. The litigation landscape is rapidly evolving, and new cases continue to be filed as evidence of systemic out-of-network billing problems accumulates.