A district court out of Connecticut recently held that the No Surprise Act (“NSA”) creates a private cause of action that allows a prevailing party to enforce an Independent Dispute Resolution (“IDR”) award. This comes as a win for providers disputing out-of-network medical bills that have encountered difficulties enforcing favorable IDR determinations against insurance companies under the NSA.
The NSA was passed under the Biden Administration and protects patients from costly, out-of-network bills for emergency services. Under the NSA, providers that disagree with the insurer’s initial payment may dispute certain out-of-network medical bills with the insurer by pursuing the IDR process. During the IDR process, an independent arbitrator reviews offers from both parties to determine the appropriate reimbursement rate for the out-of-network services the patient received. The process concludes upon the IDR entity’s selection of the appropriate reimbursement rate, and, under the NSA, if the provider wins, the insurer must pay the selected rate within 30 days.
Despite the plain language of the NSA requiring payment within that 30-day timeframe, many providers face challenges recovering reimbursement from insurers. This issue of recovery was one of the underlying points in Guardian Flight LLC, et al. v. Aetna Life Insurance Company, et al., No. 3:24-CV-00680-MPS, 2025 WL 1399145[KD1] (D. Conn. May 14, 2025), in which the plaintiff alleged the defendants, two health insurance companies, failed to fully or timely pay them in accordance with the IDR determination. The defendants fought the plaintiff’s claim on grounds the NSA does not allow for judicial review of the determination, an argument rejected by the Connecticut district court Judge Michael P. Shea. Instead, Judge Shea found that the NSA does create a private cause to enforce NSA awards, and any other interpretation of the NSA would render it meaningless. Judge Shea’s decision reinforces the NSA and is a win for providers.
[KD1] https://ecf.ctd.uscourts.gov/cgi-bin/show_public_doc?2024cv0680-264
