Physicians and practices win most No Surprises Act payment disputes. Collecting on those wins is another matter.
Two federal appeals courts have now ruled that providers cannot sue insurers to enforce unpaid independent dispute resolution awards, and the Supreme Court declined to take up the question in January. That leaves enforcement largely with federal and state regulators, even as providers file new lawsuits over millions of dollars in unpaid awards.
Here are eight things to know about where IDR enforcement stands.
1. Providers win most disputes, but some awards go unpaid
Providers, facilities and air ambulances prevailed in about 85% of federal IDR payment determinations in the second half of 2025, down from 88% in the first half of the year, according to CMS data. Providers started 2.6 million new disputes in 2025, a 77% jump from 2024, and the median prevailing provider award was 445% of the qualifying payment amount, according to a Georgetown University analysis of federal data.
There is no federal count of how many awards go unpaid. Individual practices have put numbers on the gap:
- Fort Worth, Texas-based Radiology Associates of North Texas said in May that it won about 95% of finalized disputes involving Blue Cross Blue Shield of Texas. More than $3.5 million in awarded balances remained unpaid, and the group said the payer had paid about 2% of awarded balances.
- Brentwood, Tenn.-based SpecialtyCare and two affiliated physician groups said in an Oct. 16 complaint that they won 1,443 IDR awards totaling about $2.75 million against two Anthem plans in Virginia. Anthem had paid about $249,800 as of Oct. 15, according to the complaint.
Anthem said in a statement that the IDR process has clear eligibility requirements and that it will continue to defend against these actions while supporting reforms that strengthen eligibility standards.
2. The 5th Circuit was first to shut the courthouse door
In June 2025, the 5th U.S. Circuit Court of Appeals ruled in Guardian Flight v. Health Care Service Corp. that the No Surprises Act does not give providers a private right to enforce IDR awards in court, unless there is clear evidence of fraud or misconduct. The court also ruled that certified IDR entities are immune from lawsuits.
Air ambulance companies Guardian Flight and Med-Trans had sued the insurer over 33 IDR awards they said were not paid on time. The court said enforcement belongs with the Department of Human Health and Services. It also rejected the providers’ ERISA claims, reasoning that patients suffer no injury because the law shields them from out-of-network costs.
Before the ruling, providers had filed hundreds of lawsuits over unpaid awards, and federal courts were split on whether the law allowed them.
3. The Supreme Court declined to step in
On Jan. 12, the Supreme Court denied the air ambulance companies’ petition to review the 5th Circuit’s decision. The petition had asked whether Congress, by making IDR awards binding and directing insurers to pay them within 30 days, meant for providers to be able to sue to enforce them.
The denial left the ruling binding in Texas, Louisiana and Mississippi. Texas leads the country in federal IDR dispute initiations.
In arguing against review, the insurer pointed to a 2023 Government Accountability Office report describing CMS’ No Surprises Help Desk, which can require insurers to pay IDR awards.
4. The 2nd Circuit followed in September
On Sept. 17, the 2nd U.S. Circuit Court of Appeals ruled in East Coast Advanced Plastic Surgery v. Cigna Health and Life Insurance Co. that providers cannot sue to enforce IDR awards. The ruling now governs federal courts in New York, Connecticut and Vermont.
The breast reconstruction practice won more than $3 million in IDR awards against Cigna, and Cigna has made no payments on them, according to the court. Cigna claims the practice engaged in fraudulent billing that caused it to overpay by $8.5 million for certain services.
The three-judge panel found that the law gives providers a right to payment and makes IDR binding, but creates no private cause of action to collect. Congress allowed courts to set aside IDR decisions on narrow grounds such as fraud, but left out the provision used to confirm ordinary arbitration awards. The court said Congress intended the law, including payment of awards, to be enforced through administrative action.
5. A Connecticut ruling went the other way, and new lawsuits keep coming
On May 14, 2025, a federal judge in Connecticut became the first to recognize an implied private right of action to enforce IDR awards, along with an enforcement right under ERISA, in a case air ambulance companies brought against Aetna and Cigna.
That case is still pending, and the 2nd Circuit’s ruling now hangs over it. In supplemental briefs filed Sept. 28, Cigna argued the appellate decision forecloses the providers’ No Surprises Act claim. The providers say they are owed about $5.07 million by Aetna and about $5.39 million by Cigna in unpaid awards.
Providers are still filing in circuits that have not ruled. SpecialtyCare filed lawsuits against Anthem in October in federal courts in Virginia, in the 4th Circuit, and Colorado, in the 10th Circuit. The Colorado lawsuit alleges Anthem paid about $107,218 of $608,652 in awards. Both lawsuits ask courts to confirm the awards under the No Surprises Act and the Federal Arbitration Act and bring ERISA claims tied to self-funded employer plans.
6. Who enforces depends on the type of plan
The law requires the losing party to pay within 30 days of an IDR decision. When a plan misses that deadline, providers can file a complaint with CMS through the No Surprises Help Desk. Which agency acts depends on how the patient is covered.
- Fully insured plans: State insurance regulators, with CMS stepping in where a state does not enforce.
- Nonfederal governmental plans: CMS.
- Private employer group plans (ERISA): The Labor Department, which can sue noncompliant plans.
- Group plans that pay late: Treasury, which can impose an excise tax.
CMS has used market conduct examinations to cite insurers for late payment. In an examination of Ambetter of Indiana, CMS found the issuer failed to pay amounts due within 30 days of IDR determinations.
7. CMS’ enforcement record is small next to IDR volume
CMS’ latest complaint and enforcement report, covering 2022 through 2025 and published in June, counted 664 closed complaints against issuers and nonfederal governmental plans for late payment after an IDR determination. That was the second most common complaint against payers.
CMS enforcement produced about $30.05 million in monetary relief across all closed investigations, not only IDR payment cases. CMS does not disclose open investigations, and complaints it refers to other agencies, such as the Labor Department, are not counted.
For scale, about 1.15 million disputes received payment determinations in the second half of 2025 alone, according to the federal departments.
Federal agencies also passed on new enforcement tools in their May 28 IDR operations final rule. Despite commenter requests, the departments declined to adopt monetary penalties or default judgment frameworks for payers that do not pay, relying instead on existing authority.
8. What comes next: state courts, a possible split and Congress
With federal claims under the No Surprises Act largely blocked in two circuits, providers may lean harder on state-law claims. The Connecticut air ambulance companies, for example, also seek damages under the state’s unfair trade practices law.
The Supreme Court is unlikely to revisit the issue unless another circuit sides with providers and creates a split, attorneys who represent payers wrote. Lawsuits pending in the 4th and 10th circuits could test that.
In Congress, the bipartisan No Surprises Act Enforcement Act would add penalties and interest for plans that miss the 30-day payment deadline and require HHS to report on enforcement actions. Sens. Michael Bennet, D-Colo., and Roger Marshall, MD, R-Kan., sponsor the Senate version, S. 2420. Rep. Greg Murphy, MD, R-N.C., introduced the House version, HR 4710, in July 2025. Physician groups including the American College of Radiology, American College of Emergency Physicians and American Society of Anesthesiologists back the bill.
Insurers are pushing in a different direction. Leaders at UnitedHealthcare, Cigna, Elevance Health and Aetna have argued a concentrated group of providers is exploiting IDR, and payers have called for tighter eligibility rules to keep ineligible disputes out of the process.
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