On September 17, the U.S. Court of Appeals for the Second Circuit handed down a fantastic ruling for payors defending against private enforcement of No Surprises Act (NSA) independent dispute resolution (IDR) payment determinations. In East Coast Advanced Plastic Surgery, LLC v. Cigna Health & Life Insurance Co., the court held that the NSA does not create a private right of action allowing out-of-network providers to sue health plans that fail to pay IDR payment determinations.

Summary of the Ruling

The NSA protects patients from surprise medical bills by requiring out-of-network providers to bill health plans directly rather than patients, and by establishing an IDR process, essentially binding arbitration through a “certified IDR entity,” to resolve payment disputes when providers and plans cannot agree on reimbursement through open negotiations.

The case involved an out-of-network provider, East Coast Advanced Plastic Surgery (ECAPS), that had won over $3 million in IDR payment determinations against Cigna under the NSA. When Cigna did not pay additional amounts claimed to be owing, ECAPS filed a federal lawsuit asserting an implied private right of action under the NSA, via the Declaratory Judgment Act seeking to enforce IDR payment determinations and to declare that Cigna had violated the NSA’s 30-day payment requirement. Cigna, on the other hand, alleged ECAPS had engaged in fraudulent billing practices resulting in $8.5 million in overpayments, and filed its own related suit.

The district court dismissed the case for failure to state a claim, and ECAPS appealed to the Second Circuit. The Second Circuit affirmed the dismissal, expressly adopting the Fifth Circuit’s ruling in Guardian Flight, L.L.C. v. Health Care Service Corp., 140 F.4th 271 (5th Cir. 2025), that the NSA does not create a private right of action.

The court’s reasoning rested on two key pillars:

• The text of the statute cuts against private enforcement. The court noted that while Congress incorporated the Federal Arbitration Act’s provision for vacating arbitration awards (9 U.S.C. § 10(a)) into the NSA, it notably did not incorporate the FAA’s provision for confirming (i.e., enforcing) them (9 U.S.C. § 9). That omission strongly suggests Congress did not intend for providers to enforce IDR awards through private lawsuits, particularly since Congress has expressly incorporated the FAA’s confirmation provision in other statutes when it wanted courts to enforce arbitral awards.
• Congress designed a comprehensive administrative enforcement scheme. The court found that Congress delegated enforcement of the NSA to the Department of Labor (DOL), the Department of the Treasury, and the Department of Health and Human Services (HHS), not to private litigants. DOL and Treasury may pursue civil actions and impose excise taxes against private employer-sponsored group health plans that fail to timely pay IDR awards, HHS may impose civil monetary penalties against state and local governmental plans, and states also have a role in enforcing the NSA against health insurance issuers. This interlocking administrative framework reflects Congress’s intent that IDR awards be enforced through agency action, not private litigation.

The court also rejected every one of the provider’s counterarguments, including that the “binding” nature of IDR payment determinations implies judicial enforceability and that the administrative enforcement mechanisms are too limited to be effective. Finally, the court confirmed that the Declaratory Judgment Act does not provide an independent cause of action, closing off that alternative theory as well.

What This Means Going Forward

This is now binding Second Circuit authority, and it joins the Fifth Circuit’s decision in Guardian Flight, which we covered here when it was decided in June 2025, reaching the same conclusion. Together, these decisions mean that in two federal circuits, out-of-network providers cannot sue in federal court to directly enforce unpaid IDR awards. Instead, they must rely on the DOL, Treasury, or HHS to pursue enforcement administratively, depending on the type of plan involved.

The decision also narrows a split that had been developing among district courts, including within the Second Circuit itself, where some Connecticut judges had found an implied private right of action while others had not. With the Second Circuit now weighing in directly, that question is settled within the circuit, though it remains open in other parts of the country that have not yet addressed it.

There are several other appeals pending regarding enforcement of IDR payment determinations, including the Ninth Circuit’s review of SpecialtyCare v. Kaiser Foundation Health Plan, Inc., 24-cv-09342-JST, 2026 WL 2043194, at *5 (N.D. Cal. July 15, 2026), appeal filed, 26-4722 (9th Cir. filed July 23, 2026). There, provider appellant’s opening brief is due November 30, 2026, with health plan appellee’s response brief currently due December 30, 2026.

Without a circuit split on the issue of a private right of action to enforce IDR payment determinations, we do not expect the Supreme Court to grant certiorari on this issue. However, if another circuit finds the NSA provides a private right of action to enforce IDR payment determinations, we expect the Supreme Court would take up the case.

In the meantime, we expect out-of-network providers to continue to assert state law causes of action in state court seeking to enforce IDR payment determinations. Although some federal courts have held that the NSA’s lack of private right of action precludes plaintiffs from bringing state law claims to enforce IDR payment determinations, e.g. SpecialtyCare Inc. v. Meritain Health, Inc., No. 25-cv-198-MN, 2026 WL 353259 at *4-7 (D. Del. Feb. 9, 2026); Nirav B. Savalia v. Anthem Blue Cross Life and Health Insurance Company, No. 8:26-cv-00736-FWS-KES, 2026 WL 2614181 at *4-5 (C.D. Cal. Sept. 3, 2026); and Jeffrey Farkas, M.D., LLC v. Aetna Life Insurance Company, 1:26-cv-4774 (BMC) at ECF No. 14 (E.D.N.Y. Sept. 2, 2026); those state law theories will likely need to be addressed on a state by state basis by state trial courts and appellate courts.