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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
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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.Client Alert

Preventing a Board Investigation

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Ohio Board of Nursing Proposes Rule Changes for Nurses

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