A federal district court has rejected a bid by healthcare providers to enforce independent dispute resolution (IDR) awards against an insurer under the No Surprises Act (NSA). The case is Guardian Flight LLC v. Health Care Serv. Corp., 2024 WL 2786913 (N.D. Tex. 2024).
Guardian Flight LLC, an air ambulance service provider, sued an insurer after it refused to pay a certified IDR entity's award for disputed services. Guardian maintained that the insurer violated the NSA and the Employment Retirement Income Security Act (ERISA) in failing to pay the IDR award.
However, the Court disagreed with Guardian and dismissed the case, finding that the NSA does not create a private right of action on providers to enforce IDR awards in federal Court. The NSA includes language that prohibits the judicial review of IDR decisions.
Furthermore, the Court found that the providers lacked standing to bring ERISA claims based on the improper denial of plan benefits. The fact that some plan participants had assigned their rights under their plans to the providers did not give them standing. The participants also lacked standing because they no longer were responsible for paying the claims and thus had no concrete injury that would give them standing to sue under ERISA. Therefore, if the plan participants lacked standing, the providers also lacked standing.
Despite this case's outcome, the Congressional Research Service produced a document entitled "IDR Process Data Analysis for the First Half of 2023," which concludes that providers prevailed in about 77% of IDR payment disputes during the relevant timeframe. According to this document, the volume of disputes continues to present challenges for the IDR system, including payment determinations beyond required timelines.
HBL has experience in all areas of benefits and employment law, offering a comprehensive solution to all your business benefits and HR/employment needs. We help ensure you are in compliance with the complex requirements of ERISA and the IRS code, as well as those laws that impact you and your employees.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.