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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

New Florida Law: Patient Overpayments Must Be Refunded Within 30 Days

December 22, 2025Effective January 1, 2026, Florida Senate Bill 1808 requires health care facilities and practitioners to refund patient overpayments within 30 days after an overpayment is identified. The law applies to overpayments tied to claims submitted to government programs or private insurers and introduces fines and disciplinary consequences for noncompliance. Providers should review billing and payment practices now to prepare for the new requirements.Client Alert

USCIS Policy Change Impacting Work Authorization: Advisory for Employers and Human Resources

December 8, 2025USCIS has issued a policy memorandum pausing immigration benefit processing for individuals from 19 high-risk countries and requiring a re-review of certain previously approved cases. This change may affect work authorization, employment verification, and workforce stability. Employers and HR teams should review impacted employees and update compliance procedures.Client Alert

CMS Releases CY 2026 Medicare Physician Fee Schedule Final Rule with Key Payment and Telehealth Updates

December 4, 2025CMS issued the CY 2026 Medicare Physician Fee Schedule Final Rule on October 31, 2025, with changes effective January 1, 2026. The Final Rule includes increases to the conversion factor, a new efficiency adjustment, updates to practice expense methodology, permanent telehealth policy changes, revised payment for skin substitutes, expanded rules for Part B drugs and biologicals, enhanced policies for Rural Health Clinics and Federally Qualified Health Centers, and new care management and behavioral health services.Client Alert

Ohio Department of Medicaid Updates: Key Changes to Physician Reimbursement Rates in Early Parenthood

December 3, 2025The Ohio Department of Medicaid has proposed amending Ohio Administrative Code Rule related to covered Medicaid reimbursements for physicians. Beginning on January 1, 2026, they are proposing an increase to rates for prenatal care, childbirth, and infant care and provider visits.Client Alert

Name, Image, and Likeness Agreements in Healthcare

November 14, 2025For example, some healthcare providers have begun to utilize "Name, Image, and Likeness" agreements to promote the brand they have created through their healthcare practice.  We have seen the most healthcare NIL activity with longevity and wellness providers, as well as orthopedics.
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