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Providers Beware: Court Sides with Insurers in No Surprises Act Arbitration

Client Alert
July 2, 2025

On June 12, 2025, the Fifth Circuit ruled in favor of Aetna and Kaiser Foundation Health Plan (Kaiser) in a pair of cases filed by air ambulance providers challenging the No Surprises Act’s (NSA’s) Independent Dispute Resolution (IDR) process’ resolution of payment disputes. The NSA is a federal law seeking to protect patients from expensive and unexpected medical costs when seeking out-of-network care. To that end, the NSA created an IDR process for out-of-network providers and insurance companies to utilize to resolve payment disputes between the parties.

In this case, the air ambulance providers argued that Aetna and Kaiser miscalculated the providers’ Qualifying Payment Amount (QPA) during IDR. The QPA is the rate used to settle out-of-network claims. According to the providers, Aetna and Kaiser intentionally calculated and utilized a low QPA during the IDR process, potentially skewing the arbitrator’s findings as to the correct amount the insurers were required to pay for air ambulance care.

However, the Fifth Circuit disagreed with the providers, holding that, while the NSA permits limited court review of IDR outcomes, legal challenges to IDR decisions must be based on clear evidence of fraud or serious misconduct. The Fifth Circuit also ruled that the third-party arbitrator was immune from suit for their decisions in the IDR process.

Following this ruling, it is clear that courts will not second-guess the decisions made during IDR absent clear evidence of fraud and serious misconduct.

The case is Guardian Flight, L.L.C. v. Aetna Health, Inc., No. 24-20204 (5th Cir. 2025).

To learn more about the NSA and its IDR process, please contact BMD Healthcare Member Daphne Kackloudis at dlkackloudis@bmdllc.com or Attorney Jordan Burdick at jaburdick@bmdllc.com.

Health LawHealthcareDaphne KackloudisJordan Burdick
Client Alert

OAAPN | Year In Review: 2026 Ohio Board of Nursing and Ohio Law Rules

February 9, 2026Find out key changes to Ohio law and the Ohio Board of Nursing rules that have directly impacted APRN practice over the past year, including Psychiatric Inpatient Documents, Intimate Examinations, Signature Authority, Duties Related to Fetal Death, Retail IV Therapy Clinics, Release from Permanent Restrictions, Disciplinary Action, Course on Drugs and Prescriptive Authority, Overdose Reversal Drugs, Office Based Opioid Treatment, Withdrawal Management for Substance Use Disorder, Safe Haven Program, and more.Client Alert

Ohio House Bill 537: Proposed Regulations for Midwives and Birthing Centers

January 28, 2026House Bill 537, introduced in the Ohio House of Representatives, proposes a comprehensive regulatory framework for certified nurse-midwives, certified midwives, licensed midwives, and traditional midwives. The legislation would clarify scope of practice, establish licensure standards, and impose new requirements for freestanding birthing centers and home births. Healthcare providers and facilities should be aware of the proposed changes and their potential operational impact.Client Alert

Proposed Health Information Privacy Reform Act Expands Protections Beyond HIPAA

January 26, 2026The Health Information Privacy Reform Act (HIPRA) seeks to extend privacy protections to health data not covered under HIPAA, including data collected by apps and wearables. HIPRA introduces broader definitions of protected health information, strengthens privacy and security requirements, establishes patient notification rights, and sets national de-identification standards. Companies processing health data should monitor developments to ensure compliance.Client Alert

Medicare Updates on Skin Substitutes: LCDs Withdrawn, Payment Changes Take Effect

January 23, 2026Medicare’s planned Final Local Coverage Determinations (LCDs) for skin substitutes were withdrawn in late December 2025, meaning previous coverage rules remain in effect. The 2026 Medicare Physician Fee Schedule introduces a single payment rate of approximately $127.14 for these products. Providers should review implications for diabetic foot and venous leg ulcer treatments.Client Alert

Understanding the Seven Core Elements of an Effective Healthcare Compliance Program

January 22, 2026The Affordable Care Act requires healthcare providers participating in Medicare, Medicaid, and CHIP to maintain an effective compliance program. Guidance from the Department of Health and Human Services and the Office of Inspector General outlines seven core elements that form the foundation of these programs, from written policies and compliance oversight to auditing, training, and corrective action. This alert highlights each element and explains how practices can tailor compliance programs to their size and risk profile while meeting federal expectations.
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