The No Surprises Act promised payers and out-of-network providers a faster alternative to litigation regarding reimbursement disputes. But, four years into the federal independent dispute resolution (IDR) process, frustration abounds for both payers and providers. The IDR process has been overwhelmed by a massive number of filings, many of which are not eligible for the process in the first place. And, the vast majority of IDR awards have favored providers. But, providers have found that winning an IDR award and collecting on it are two different things.
On September 17, 2026, the Second Circuit held that a provider holding more than $3 million in unpaid IDR awards has no private right of action to enforce them, leaving administrative complaints to regulators as its only recourse. The decision in East Coast Advanced Plastic Surgery, LLC v. Cigna Health & Life Insurance Co. marks an important development in litigation regarding the enforceability of IDR awards in federal courts.
Challenges with the IDR Process
Dispute volume has vastly exceeded what regulators projected. In 2025 alone, total dispute initiations reached 2.56 million, roughly 115 times the government’s initial estimate. That volume has coincided with lopsided outcomes. Providers have prevailed in the substantial majority of arbitrated cases, and in 2025, the median award across all disputed line items ran nearly four times the Qualifying Payment Amount (QPA) and about 5.5 times the Medicare rate for the same services.[1]
Taken together, these trends suggest the IDR process is increasingly functioning less as a narrow backstop for atypical out-of-network disputes and more as a routine, alternative payment pathway. High provider win rates and awards well above in-network rates may weaken providers’ incentive to join insurer networks in the first place, since the IDR process can yield better returns than a negotiated contract. Over time, that dynamic could result in fewer providers contracting in-network, more disputes routed to arbitration, and upward pressure on in-network rates as insurers compete to keep providers under contract.
Several factors appear to be compounding the strain. Recent analyses suggest that litigation challenging the QPA’s role as the primary benchmark in the IDR process, which was intended to keep awards near contracted rates, has increased the attractiveness of the IDR process and driven payment obligations upward. The process also has drawn significant participation from private equity-backed firms that specialize in filing disputes at scale, a dynamic that industry groups point to as a driver of volumes that have exceeded original projections by multiple orders of magnitude.[2]
In response, the Departments recently finalized a rule aimed at making the arbitration system more efficient. Among other changes, it requires insurers to provide clearer information upfront, formalizes the open negotiation process through the federal IDR portal, expands and clarifies rules for batching similar claims together, speeds up eligibility determinations, and creates a registry to help providers identify the correct health plan on the other side of a dispute.[3]
However, even with these reforms, many of the underlying tensions in the IDR process have already spilled into the courts. Most of the litigation to date has centered on a narrow but consequential question: whether providers may sue to collect on unpaid IDR awards.
Provider Lawsuits
Providers have filed a wave of cases in federal district courts across the country attempting to enforce IDR awards, claiming that the NSA created an implied right of action to enforce IDR awards and that such awards can be confirmed pursuant to section 9 of the Federal Arbitration Act. Indeed, one provider alone has filed hundreds of cases attempting to enforce IDR awards in just a single federal district court.
Courts have reached varying results as to whether IDR awards are enforceable. In Guardian Flight, L.L.C. v. Health Care Service Corporation, the Fifth Circuit Court of Appeals held that the NSA does not imply a private right of action to enforce IDR awards. But, some district courts outside of the Fifth Circuit declined to follow the Guardian Flight decision and held that providers could bring suit under the NSA to enforce IDR awards.
The Second Circuit’s Decision in East Coast Advanced Plastic Surgery v. Cigna Health and Life Insurance Company
In East Coast Advanced Plastic Surgery v. Cigna Health and Life Insurance Company, the Second Circuit joined with the Fifth Circuit to hold that the NSA does not provide an implied private right of action to enforce IDR awards and that IDR awards must be enforced through the administrative scheme that Congress created in the NSA. The Second Circuit held that the fact that the NSA cross-references the FAA’s vacatur provision but not its confirmation provision is strong evidence that Congress did not intend to imply a private right of action. The Second Circuit further emphasized that the NSA contains a “comprehensive” administrative enforcement scheme. The NSA was “triple” codified—the NSA amended ERISA, the Internal Revenue Code, and the Public Health Service Act (PHSA)—and delegates enforcement authority to federal agencies and to states:
- The Department of Labor may file civil lawsuits against non-compliant private-sector group health plans to enforce compliance with the IDR process;
- The Department of Treasury may impose a tax when a private-sector group health plan fails to timely pay an IDR award;
- The Department of Health and Human Services may impose civil monetary penalties on state and local group health plans that do not timely pay IDR awards.
- The PHSA permits states to enforce the NSA against health insurance issuers.
Notably, the Second Circuit rejected the following arguments made by the provider:
- The agencies have not actively enforced the NSA and have the authority to waive enforcement. The Second Circuit held that the relevant question is whether Congress gave an agency enforcement authority—not whether they utilize or waive it.
- Disallowing a private enforcement remedy would undermine the IDR process. The Second Circuit held that there is an administrative process for enforcement of the NSA, so the absence of a private right of action does not undermine the statute.
What’s Next?
The Second Circuit’s decision marks an important development in litigation regarding the enforcement of IDR awards, but it does not signal the end to all litigation on this issue. With the door to enforcement of IDR awards under the NSA all but shut by the decisions in Guardian Flight and East Coast Advanced Plastic Surgery, providers may double-down on their efforts to enforce IDR awards through state law causes of action. Indeed, earlier this year, one federal district court stayed hundreds of cases where a provider expressed its intention to amend its complaints attempting to enforce IDR awards under the NSA to add state law claims.
We continue to monitor policy and litigation developments related to the NSA and Federal IDR process. For more information on the NSA and Federal IDR, see our prior NSA publications:
- CMS Announces Updates Regarding IDR Operations and Portal | Groom Law Group
- The Departments Issue Final IDR Operations Rule | Groom Law Group
- No Surprise Bills for Patients, But Plenty of Complexity for Payers: An Update on the No Surprises Act | Groom Law Group
[1] Fixing the No Surprises Act: Scaling Back and Reforming the Federal Arbitration System
[2] 9-17-26-Compressed-ERIC_NSA_White_Paper_Formatted_FINAL-440.pdf
[3] 91 FR 33900 Federal Register :: Federal Independent Dispute Resolution Operations
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