Beginning in 2021, the Federal No Surprises Act (NSA) prohibited out-of-network health care providers from “balance billing” patients for certain types of care when, as is frequently the case, the patient’s insurer reimbursed the provider at far less than the provider’s charges. The NSA covers all emergency services, as well as non-emergency services provided by out-of-network providers at in-network facilities. Under the relevant NSA provisions, out-of-network providers who are not satisfied with the reimbursement from the insurer are required to challenge the payment amount in an Independent Dispute Resolution (IDR) proceeding, which is similar to arbitration.
One year ago, a Federal District Court in Texas held that providers had no right to enforce a favorable IDR decision: “[T]he NSA does not create a procedural mechanism for [providers] to enforce their IDR awards in federal court.” Guardian Flight LLC v. Health Care Serv. Corp., 735 F. Supp. 3d 742, 750 (N.D. Tex. 2024). This shocking decision was potentially devastating for out-of-network providers, since the NSA prohibits them from balance billing patients, requiring them to rectify the underpayment through IDR, but the Texas court decision meant that even when providers prevail at IDR, insurers are still free to simply refuse to pay.
On May 14, 2025, Judge Michael P. Shea of the Connecticut District Court soundly rejected the Texas NSA decision, and held that “the NSA creates a private cause of action to enforce IDR awards.” Guardian Flight LLC, et al. v. Aetna Life Insurance Company, et al., No. 3:24-CV-00680-MPS, 2025 WL 1399145, at *9. Judge Shea noted the obvious anomaly that the reasoning of the Texas court “would render IDR awards meaningless . . .” except in circumstances where the insurer prevails. Id.
While the NSA does not specifically state that providers may judicially enforce IDR awards, Judge Shea noted that “courts have recognized that a private right of action may be implied if there are no enforcement mechanisms or express remedies available, such that without an implied private cause of action, plaintiffs would have no remedy to the legislatively recognized harm.” It is precisely this “absurd result” of the reasoning in the 2024 Texas decision that Judge Shea found unacceptable.
While good news for out-of-network providers, Judge Shea’s decision is by no means the final word on this issue. Neither of the two differing District Court decisions on the enforceability of IDR awards are binding on other courts, and insurers are unlikely to abandon the argument that they are free to ignore obligations to reimburse providers as required in the NSA, based solely on the recent Connecticut decision.[1]
In sum, among the difficulties and confusion that the NSA has created for out-of-network providers, the threat that providers will be denied relief even when they successfully navigate the NSA continues.
Should you have any questions regarding the NSA, including enforcement of IDR awards, please contact the author, the Garfunkel Wild attorney with whom you regularly work, or contact us at [email protected].
[1] The Texas decision is being challenged on appeal, and it was argued early this year.