2 appeals courts block suits over unpaid No Surprises Act awards. Here's what practices can still do

A practice can win more than $3 million in No Surprises Act arbitration and still have no way to make the payer pay through a federal lawsuit. That was the outcome Sept. 17, when the 2nd U.S. Circuit Court of Appeals ruled in East Coast Advanced Plastic Surgery v. Cigna that the law gives providers no private right to enforce independent dispute resolution (IDR) awards.

Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association (MGMA), told Physicians Practice in June that providers prevail more than 80 percent of the time "only to receive no payment." He called for "more accountability so that when a provider prevails in the IDR process, they actually get paid in a timely manner." For now, that accountability has to come mainly from regulators.

The 2nd Circuit joined the 5th Circuit, which reached the same result in June 2025 in Guardian Flight v. Health Care Service Corp. The Supreme Court declined to review that decision Jan. 12. Federal courts in Texas, Louisiana, Mississippi, New York, Connecticut and Vermont are now bound by those rulings.

Trial courts elsewhere have split. A federal judge in Chicago dismissed similar claims Aug. 5. In March, a federal judge in Maryland let a suit over about $31,000 go forward. "The clear text and structure of the No Surprises Act entitles prevailing parties to judicial enforcement of IDR awards," U.S. District Judge Adam Abelson wrote.

Cigna has not paid the awards in the New York case. It alleges the practice billed fraudulently and was overpaid by $8.5 million, according to Becker's Payer Issues. The appeals court did not resolve that dispute.

What's at stake

Providers won 85 percent of the 1.15 million disputes that reached a payment determination in the second half of 2025, according to federal data. There is no federal count of how many of those awards go unpaid.

A survey of clinicians in 45 states, cited in an April 27 letter from more than 100 physician organizations, found 22 percent of 2023 awards and 11 percent of 2024 awards had not been paid. Half of the 2024 payments that were made came after the 30-day deadline.

Individual groups report worse. Radiology Associates of North Texas said Blue Cross Blue Shield of Texas had paid about 2 percent of its awarded balances. SpecialtyCare said Anthem had paid about $249,800 of $2.75 million in Virginia and about $107,218 of $608,652 in Colorado. Anthem said it will defend against the suit in Virginia and that the IDR process has clear eligibility requirements.

Where to go when a payer doesn't pay

The right route depends on who is on the hook, so identify the plan type first. The 2nd Circuit laid out the enforcement scheme in its opinion. It also made clear that weak enforcement doesn't reopen the courthouse. The practice argued the Labor Department does little to enforce awards, and Circuit Judge Michael Park answered that "the relevant question is whether Congress authorizes agency enforcement, not how actively the agency exercises its authority."

• Start with CMS. File through the No Surprises Help Desk at 800-985-3059 or the online complaint portal. Supporting documents may be required, so attach the determination, the due date and your payment records. Keep expectations in check: CMS' latest report counted 664 closed complaints against issuers and plans for late payment after an IDR determination from 2022 through 2025. Total monetary relief across all closed complaints of every type was about $30.05 million.
• Fully insured plans. File with the state insurance regulator too. States may enforce the law against issuers, and CMS steps in where a state does not.
• Self-funded employer plans. The Labor Department can sue private employer plans, and Treasury can impose a tax for late payment. State insurance departments are not the route here, but a CMS complaint still creates a record.
• State and local government plans. HHS can impose civil money penalties.
• State unfair trade practice claims. Treat these as a long shot. Air ambulance companies are seeking damages under Connecticut's unfair trade practices law, and Cigna argues the East Coast ruling supports its bid to defeat that claim. The Chicago judge threw out a claim under Illinois' consumer fraud law. On Sept. 17, a New York state judge dismissed seven state-law claims by two Long Island practices seeking more than $1.7 million from Anthem, finding they depended on the federal IDR process. That ruling is from a trial court, and other states may land elsewhere.

Attorneys at Harris Beach Murtha point to stronger footing when a payer made its own commitment, through a contract or a clear promise to pay. Save those emails and portal messages, and talk to health care counsel before filing. Our nine-step collections checklist covers the tracking and demand work that should come before any complaint.

How much to reserve

We could not find a published reserve rate for unpaid IDR awards from a regulator or accounting body, so practices should set one from their own payment history with their accountant.

Calculate each payer's collection rate on awards more than 30 days past determination, then reserve the rest of what's open. If a payer has paid 40 percent of its awards, $100,000 in open awards calls for a $60,000 reserve. Leave those dollars out of cash forecasts until they arrive.

That approach tracks general accounting practice. PwC's health care accounting guide, which does not address IDR awards specifically, says providers often use historical collection rates for similar groups of patients to estimate revenue, and should hold back amounts that may have to be reversed later.

With no history on a payer, treat the 11 percent unpaid rate in the physician survey as a floor, not an estimate. It comes from physician groups, and the Texas and SpecialtyCare numbers show one payer can run far higher.

What comes next

The question isn't settled nationally. Appeals on the same issue are pending in the 3rd, 7th and 9th circuits. The 7th Circuit consolidated five of them Aug. 27, and the payer's response brief is due Nov. 9. In the 9th Circuit, the provider's opening brief is due Nov. 30 in SpecialtyCare v. Kaiser Foundation Health Plan.

The 4th and 10th circuits have not ruled, but cases are building there. The Maryland decision sits in the 4th Circuit, and SpecialtyCare sued Anthem in October in federal courts in Virginia and Colorado, in the 4th and 10th circuits. Attorneys who represent payers wrote that they would expect the Supreme Court to step in only if another circuit sides with providers.

Congress could also change the math. The bipartisan No Surprises Act Enforcement Act, HR 4710 and S. 2420, would add a penalty of three times the unpaid difference plus interest for missing the 30-day deadline. It faces opposition from the Coalition Against Surprise Medical Billing, which represents employers and insurers, and from the AFL-CIO, which told senators in September that it "will fuel additional abuse of IDR." It remains a proposal, so practices should not budget around it.