According to a recent decision by the Fifth Circuit Court of Appeals (the “Court”), providers cannot use private lawsuits to compel health plans to pay amounts awarded through the federal No Surprises Act’s (“NSA”) out-of-network independent dispute resolution (“IDR”) process. In its June 12, 2025, ruling in Guardian Flight, L.L.C. et al. v. Health Care Service Corp., the court held that NSA does not create a private right of action for providers to enforce IDR awards issued in their favor.
Background
Generally speaking, the NSA aims to prevent “surprise billing,” which refers to unexpected medical bills from out-of-network (“OON”) providers or facilities. Under the NSA, when a patient receives OON emergency care or is treated by an OON provider at an in-network facility, the patient can only be charged their in-network cost-sharing amount for the OON item or service. For further discussion of the surprise billing prohibition and patient cost-sharing protections under the NSA, please refer to our previous article available here.
The NSA also established a “baseball style” IDR process in which an IDR Entity settles payment disputes between payers and OON providers regarding the OON rate for items/services subject to the surprise billing protections under the NSA. This process is completely independent of the patient cost-sharing protections and is only available if the OON rate for such items/services is not otherwise determined based on a specified state law or an All-Payer Model Agreement, and if the parties fail to come to an agreement through a mandated informal good-faith negotiation period. For further discussion regarding the IDR process under the NSA, please refer to our article here.
In this case, Guardian Flight and Med-Trans Corp. (“Guardian Flight”), both air-ambulance providers, filed suit in district court against the Health Care Service Corporation (“HCSC”) for their failure to timely pay the total OON payment amount for services rendered by Guardian Flight to HCSC members, as determined through the NSA IDR process. The district court found in favor of HCSC, stating that the NSA does not contain a private right of action. Guardian Flight appealed to the Court.
Court’s Analysis
The Court affirmed the lower court’s ruling, agreeing that no private right of action exists under the NSA. The Court reasoned the NSA expressly states that an IDR award “shall not be subject to judicial review,” except in certain cases permitted under the Federal Arbitration Act – circumstances in which Guardian Flight conceded did not apply. The Court further noted that since there was no express right of action to enforce an IDR award under the NSA, there is a presumption that Congress did not intend to create one.
Guardian Flight attempted to overcome that presumption by arguing it was seeking judicial “enforcement,” not judicial “review.” However, the Court did not agree with this argument, holding that seeking to enforce an IDR award constitutes judicial “review.” The Court emphasized that it “does not find an implied right of action where Congress expressly forecloses it,” and thus ruled in favor of HCSC.
Notably, this decision directly contradicts a recent opinion from the U.S. District Court for the District of Connecticut, which found that a private right of action does exist under the NSA. This contradiction could result in a split among the appellate courts that may require a resolution by the U.S. Supreme Court or further legislative clarification from Congress.
Practical Takeaways
- No Private Right of Action to Enforce IDR Awards. The Court confirmed the NSA does not allow providers and facilities to bring lawsuits to enforce IDR decisions. At this time, a provider or facility’s only recourse is to submit a formal complaint to the Centers for Medicare & Medicaid Services (“CMS”) of the health plan’s noncompliance with the NSA IDR process by calling the CMS Help Desk at 1-800-985-3059 or by submitting a complaint online.
- Conflicting Rulings Raise Legal Uncertainty. This decision contradicts a recent district court decision. Depending on how the split is resolved, providers hoping to enforce an IDR award may, eventually, be able to enforce the award in court.
- Advocacy May Be Needed for Legislative Fix. The case highlights a potential gap in the NSA’s enforcement framework. Stakeholders may consider advocating for clearer statutory language granting enforcement authority to providers when health plans fail to pay in a timely manner.
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- Lisa Lucido at (248) 457-7812 or llucido@hallrender.com;
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- Abby Kaericher (202) 472-9674 or akaericher@hallrender.com;
- Matt Reed at (317) 429-3609 or mreed@hallrender.com;
- Kennedy Bunch at (317) 977-1420 or kbunch@hallrender.com; or
- Your primary Hall Render contact.
Hall Render blog posts and articles are intended for informational purposes only. For ethical reasons, Hall Render attorneys cannot—outside of an attorney-client relationship—answer specific questions that would be legal advice.
