BENEFITS DIGEST

Three organizations that decide surprise-billing payment disputes (i.e., National Medical Reviews, Keystone Peer Review (doing business as Acentra) and MCMC) are up for recertification as federal independent dispute resolution entities, and CMS has opened a window for public petitions to deny them. The window runs October 23 through October 29, five business days. A petition needs the agency’s form and supporting documents, and CMS acknowledges petitions within ten days, which is a receipt, not a decision deadline. For the plans and administrators who live with these arbitrations, the petition window is the rare moment to put concerns about a particular entity on the record.

The surprise-billing arbitration system worked as Congress designed it, SpecialtyCare’s October 23 complaint says, except for the last step, the insurer paying. The surgical-monitoring provider wants about $280,856 in federal dispute-resolution awards it says Anthem Health Plans of Kentucky never paid, and it pleads six alternative routes to collection spanning the No Surprises Act, arbitration law and ERISA, including theories that it stands in patients’ shoes because they signed their claims over to it and that Anthem acts as a fiduciary when it decides these claims. The complaint candidly acknowledges that some courts, including two federal appeals courts, have held providers have no private right to enforce the awards.

The Second Circuit held September 17 that the No Surprises Act doesn’t give providers a private right of action to enforce arbitration awards against plans, joining the Fifth Circuit and affirming dismissal of a provider’s collection suit. The court relied on the statute’s text and its scheme of agency and state enforcement, and found the Declaratory Judgment Act supplies no independent cause of action. Awards remain binding and payment obligations persist through other enforcement channels, and a footnote expressly leaves open how far the statute’s judicial-review bar reaches.

SpecialtyCare and two physician groups sued Anthem Health Plans of Virginia and HealthKeepers on October 16 over federal surprise-billing arbitration awards for out-of-network intraoperative neuromonitoring, the tracking of a patient’s nerve function during surgery, that the insurers allegedly never paid. The providers allege that $2,501,372 remains unpaid, and the complaint pleads several alternative routes to enforcement under the No Surprises Act, the Federal Arbitration Act and ERISA, with the ERISA counts limited to awards involving self-funded plans. For plan sponsors, the case tests what happens when the surprise-billing arbitration system produces awards that go unpaid. Whether any of the enforcement theories holds up is now the court’s question.

True North Medical of Suffolk and a fellow provider have appealed, in a case [docketed](https://www.courtlistener.com/docket/74971039/true-north-medical-of-suffolk-pc-v-aetna-inc/) in the Second Circuit on October 15, from Judge Kiyo Matsumoto’s September 16 ruling dismissing their bid to confirm No Surprises Act arbitration awards against Aetna for lack of federal jurisdiction. The district court held that the Federal Arbitration Act supplies no independent jurisdiction and found no implied right of judicial enforcement in the No Surprises Act itself, while expressly not deciding that Aetna owes nothing. The dispute concerns how providers can enforce unpaid No Surprises Act arbitration awards.

Rep. Frank Pallone’s Lower Premiums, Faster Payments Act would replace federal surprise-billing arbitration with a payment standard tied to the qualifying payment amount, generally an inflation-adjusted median contracted rate. The proposal would apply to services furnished beginning January 1, 2028, and require payment within 30 days of receiving the bill. It would also revise how the qualifying payment amount is calculated, including treatment of expected bonuses and risk-sharing payments, and expand audits. The existing statutory roles for specified state laws and all-payer models wouldn’t simply disappear. Holland & Knight explains the proposed shift away from case-by-case arbitration; the bill text shows why the calculation of the payment benchmark would become even more consequential. This is a proposed overhaul, not a change employers should implement now.

Rep. Frank Pallone is proposing to replace federal surprise-billing arbitration with payments tied to a statutory benchmark. Healthcare Dive examines the proposal against complaints about the cost and volume of the existing dispute process and disagreement among healthcare stakeholders over how out-of-network care should be paid. Moving away from individual arbitration would make the payment benchmark—generally an inflation-adjusted median contracted rate—more consequential. The proposal remains legislation under discussion, not a payment rule plans can begin applying. Providers and plans would face different incentives under a fixed benchmark, which helps explain why reform is contested.

Anthem’s Virginia plans sued AGS Health, the billing manager for a network of Schumacher emergency physician groups, alleging a scheme of falsely attesting that thousands of billing disputes were eligible for No Surprises Act arbitration, many of which Anthem says belonged under Virginia’s own balance billing law instead. Judge Robert S. Ballou dismissed all ten counts with prejudice. The court rejected Anthem’s attempt to challenge the awards through separate racketeering, benefits-law and state-law claims. Challenges had to fit the narrow grounds for overturning arbitration awards, and Anthem’s allegations did not meet that test. Anthem raised its eligibility objections during the arbitrations and the arbitrators rejected them, which defeated the fraud theory, and arbitrators empowered to decide eligibility do not exceed their powers by deciding it. The opinion joins a line of 2026 decisions reaching the same result against Anthem, Aetna and Blue Cross plans in California, Florida, Texas and Georgia.

Air ambulance operator PHI Health sued Anthem, dozens of employers and their health plans in Kentucky on October 6, seeking $2.6 million in unpaid balances on 116 No Surprises Act arbitration awards. Defendants include Walmart, Amazon, Toyota and the University of Kentucky. Beyond collecting the awards, PHI alleges that plan fiduciaries failed to respond to warning signs about Anthem’s payment practices. The complaint cites demand letters, other lawsuits and trade reporting that allegedly put them on notice, and says Anthem had accumulated more than a thousand unpaid awards approaching $30 million nationwide. PHI asks for corrective action that could include replacing Anthem as administrator, along with monetary relief. The court hasn’t ruled on those allegations.

Rivkin Radler recaps East Coast Advanced Plastic Surgery v. Cigna, No. 25-2204, the September 17 decision in which the Second Circuit held that the No Surprises Act gives an out-of-network provider no private right of action to enforce awards from the independent dispute resolution process. The provider had won more than $3 million in awards that the statute says must be paid within 30 days, and sued when Cigna did not pay. The court concluded that Congress provided administrative enforcement but did not authorize providers to sue under the No Surprises Act itself to collect the awards. The awards remain valid, and CMS can still enforce them. Cigna’s separate allegation that the provider’s billing practices produced roughly $8.5 million in overpayments is still being litigated. The decision limits providers’ ability to use the No Surprises Act itself to collect unpaid awards in federal court.

Hall Benefits Law recaps PHI Health’s suit against Anthem, the air-ambulance operator’s claim that the insurer and the plans it administers haven’t paid about $30 million in final awards from the No Surprises Act’s independent dispute resolution process, plus more than $1.3 million in interest. IDR determinations are binding and payment is generally due within 30 days, yet it remains unsettled whether a court can actually compel payment of an unpaid award, which is what this Indiana federal case may answer. PHI also alleges Anthem delayed and underpaid awards to pressure providers into below-market network deals. The roughly 70 employer plans named alongside Anthem, and every self-funded sponsor it administers, have a direct stake in the answer.

When the No Surprises Act passed, regulators projected about 22,000 payment disputes a year. Providers initiated 2.6 million in 2025, and of the disputes that reached a decision, providers won 85%, at a median award more than four times the plan's median in-network rate. Research cited in a Georgetown University analysis puts costs attributable to the arbitration process at $22.4 billion from 2022 through 2025. The post explains the process, in which each side proposes a payment and the arbitrator must pick one number or the other, and the September letter in which 67 employer, consumer and patient groups asked Congress to replace arbitration with a predictable benchmark payment. Employers with self-funded plans should ask their claims administrator how many disputes involve their plan and what the awards are costing. Choosing in-network care can reduce exposure, but it doesn't eliminate surprise bills from out-of-network clinicians working at in-network hospitals.

A surgery center that won a $71,888.85 arbitration award under the No Surprises Act and never got paid can't sue to collect it, Magistrate Judge Nathanael Cousins held, dismissing every claim without leave to amend. The court found no private right of action to enforce independent dispute resolution awards, agreeing with the Fifth Circuit's Guardian Flight decision and with the Second Circuit's September ECAPS ruling: enforcement belongs to the agencies through penalties, not to providers through lawsuits. The provider's fallback ERISA claims failed for lack of standing because the patient, fully insulated from the unpaid balance, suffered no injury the assignment could carry. State law claims could not fill the gap. The upshot of this ruling is specific: the provider holds an arbitration award the plan hasn't paid, and this court closed every route it offered for collecting it.

A collection fight over surprise-billing arbitration awards has arrived on employers' doorsteps. PHI Health, an air ambulance operator, [filed suit](https://digest.theinnerfirm.com/docs/phi-health-v-anthem-complaint-2026-09-15.pdf) in federal court in Indiana on September 15 to collect just over $4.3 million it says Anthem left unpaid on awards issued through the No Surprises Act's independent dispute resolution process. One claim targets the plan sponsors directly. PHI alleges they breached their duties by choosing and keeping Anthem and failing to monitor whether it paid the arbitration awards. That claim names the sponsors, not Anthem. The defendants include roughly 70 employer and union-affiliated plans and their sponsors, among them Eli Lilly, General Motors, Walmart, Kroger, State Farm, Indiana school corporations, and joint union-employer benefit funds. The complaint also claims plan benefits directly under ERISA using payment rights transferred by the patients PHI transported. PHI asks the court to enforce the awards under the No Surprises Act itself or, alternatively, under the Federal Arbitration Act on the theory that participating in the arbitration process creates an enforceable agreement. Whether those statutes allow this kind of collection suit is a disputed question. These are allegations at the filing stage, and no defendant has responded. Self-funded sponsors whose administrators handle these disputes now have a concrete reason to ask how the awards are being paid.

The out-of-network payment fight can run in either direction, and in this case the insurer was the one suing. United Healthcare sued three Georgia emergency medicine groups affiliated with TeamHealth in 2023, alleging they overcharged patients in employer-sponsored plans for out-of-network services and arguing that ERISA plan terms, not the providers' billed charges, control what gets paid. Hall Benefits Law reports the parties have settled on undisclosed terms and the court has closed the case, with nothing decided on the merits.

Changes to the federal surprise-billing arbitration process are [taking effect in stages](https://www.cms.gov/files/document/federal-idr-operations-implementation-timeline.pdf). The federal administrative fee fell from $115 to $15 per party for disputes initiated on or after June 11. New requirements for codes explaining claim payments and denials apply to services furnished beginning January 1, 2027. Other changes, including plan registration and moving negotiations into the federal portal, follow separate implementation schedules, and CMS is launching audits of the certified arbitration entities amid questions about arbitrator bias. Seyfarth's alert walks through the operational side for plan sponsors. On the legal side, Troutman Pepper Locke explains the Second Circuit's ruling that providers cannot sue under the No Surprises Act to collect unpaid arbitration awards, because Congress gave enforcement to the agencies. One Maryland district court has disagreed, and appeals raising the question are pending in other circuits, including the Ninth Circuit's SpecialtyCare v. Kaiser. Providers are also turning to state-law collection theories, which three district courts have already rejected. Ask your administrator which requirements are already in effect and whether its systems meet them.

After East Coast Advanced Plastic Surgery v. Cigna, No. 25-2204 (2d Cir. Sept. 17, 2026), the next front is providers pivoting to state-law claims, with one district court already staying hundreds of provider suits pending amended complaints, per Groom's Daniel Mulligan. His alert also traces the holding to a drafting tell. The statute lets a party ask a court to set aside an arbitration award but never provides for court enforcement of one. The volume behind the fight is striking. In 2025, 2.56 million disputes were initiated, roughly 115 times what the government projected. Kantor & Kantor's Peter Sessions fills in the fight itself, including Cigna's counterclaim that the practice's billing caused $8.5 million in overpayments.

Harris Beach's read on East Coast Advanced Plastic Surgery v. Cigna, which we covered Monday, is most useful on what may remain after the ruling: the firm suggests providers may still have contract or promissory estoppel claims where a payor made enforceable commitments around the IDR process, while acknowledging the decision leaves other enforcement routes uncertain. Context for the stakes: the provider there had won more than $3 million in IDR awards it alleged went unpaid, and the ruling limits the collection lawsuit, not the obligation to pay.

Thursday's Second Circuit ruling limits providers' ability to sue under the No Surprises Act to collect arbitration awards. It doesn't cancel the awards or the obligation to pay them, and regulators can still enforce payment. Thompson Hine's alert says a plan with grounds to challenge an award should review its options with counsel, and counts self-insured plans as the named responding party in roughly 68 percent of last year's disputes. The firm also recommends asking claims administrators for plan-specific arbitration results and using them in cost forecasts. On the administrative side, [Segal reports](https://www.segalco.com/consulting-insights/idr-operations-update-a-new-gateway-and-guidance-on-codes/) that registration opened September 15 for the new federal dispute-resolution portal, expected to launch late this year, and that required payment-explanation codes apply to services provided on or after January 1, 2027. Plans that outsource this work should confirm their administrator is preparing for both changes. McDermott Will & Schulte's broader survey of NSA litigation and reporting developments is [here](https://www.jdsupra.com/legalnews/no-surprises-act-developments-in-7201130).

The employer coalition opened a new front in the No Surprises Act fight. The ERISA Industry Committee, whose board includes ExxonMobil, Lockheed Martin, PepsiCo and Walmart executives, released a report Thursday and briefed both chambers, arguing arbitration fees are landing on self-funded plans. One employer reports more than $6 million in dispute payments in the first half of the year, and Mercer projects employer coverage costs up 8.5 percent next year, the steepest climb in nearly a quarter century. ERIC wants awards anchored to the in-network benchmark rate, the approach the Fifth Circuit's August ruling (covered here September 11) held had let insurers keep rates artificially low, and the doctors' groups and their House allies call that a non-starter. Everyone agrees on the vehicle: the year-end spending bill.

The provider-side counterweight, built on [Georgetown's analysis of the 2025 dispute data](https://chir.georgetown.edu/the-no-surprises-act-idr-process-an-early-look-at-2025-data/) that both sides are citing. Providers won 88 percent of disputes in the first half of 2025, the highest rate recorded, and median awards ran at multiples of the in-network benchmark. DWT's tally by specialty tops out at roughly 32 times the benchmark for breast implant and reconstruction, the specialty of the provider who just lost the Second Circuit enforcement case above. The firm's advice to providers is direct. With the filing fee cut from $115 to $15 per party in June, and eligible claims from the same patient visit now allowed to be combined into one dispute, underpayments once too small to arbitrate may be worth pursuing. Their answer to the cost critique is that rising IDR spending reflects meritorious claims, not a broken system.

Inside the firm at the center of the volume fight. HaloMD files roughly a fifth of the nation's IDR disputes for more than 150 medical groups, mostly small and mid-sized independent practices, wins over 90 percent of them, and draws median payouts nine times in-network rates. Patrick Velliky, its chief external affairs officer, concedes the research assumptions critics attack while insisting the underpayment problem is real. “On the payer side, there are companies that offer $1 or $0,” he says, and the lawsuits, he argues, came because small groups “would suddenly be able to stand up for themselves.” He even endorses one reform, CMS scrutiny at recertification of whether arbiters lean toward the parties that bring them business. The machinery keeps growing either way. HHS just certified Physio Solutions, doing business as Meditlitix, as the seventeenth IDR entity.

The case behind the Second Thing, and what the lead leaves out. This was a two-front war. Cigna sued first, alleging ECAPS's billing caused $8.5 million in overpayments, and ECAPS answered with the enforcement suit the court just ended. Judge Park's opinion, joined by Judge Leval and Judge Rakoff sitting by designation, resolves a split among district courts, including within the circuit, and rejects the Declaratory Judgment Act as a workaround because it “does not create an independent cause of action.” The panel did not reach Cigna's broader argument that the Act's judicial-review bar independently forbids such suits, so that question awaits another case. MultiPlan, dismissed below, did not participate in the appeal.

Independent dispute resolution, the federal process for resolving surprise-billing payment disputes between plans and providers, is getting a new front door. CMS's IDR Gateway page lays out the transition: account creation is open now, the full move comes late this year, and the current web forms stop working January 15, 2027, with one narrow resubmission exception. Anyone who processes disputes, represents parties or submits IDR forms must enroll and complete identity verification, only U.S.-based users may access the system, and where a third-party administrator handles disputes it is the administrator that registers. [Bracewell's client alert](https://www.bracewell.com/resources/no-surprises-act-idr-portal-changes/) reads the payer-registration requirement as good news for providers, who will finally know who they are negotiating with, and predicts the accompanying response requirement should keep more disputes from escalating to full arbitration, while cautioning that the portal does nothing about the process's biggest unsolved problem, collecting payment after a determination. Plans and their administrators should sort out who will register and handle disputes before the old forms shut off.

The IDR machinery gets some plumbing: federal agencies released nine new remittance advice remark codes so payers can tell providers exactly why a claim is not surprise-billing material—a state law limits the reimbursement, the claim is ineligible for IDR, the service is not covered. The codes supplement the existing claim adjustment reason codes and become mandatory January 1, 2027. Small as it sounds, clearer remittance coding aims at the front end of the dispute pipeline, where miscommunication feeds the arbitration volumes the agencies have been trying to tame all year.

A litigation-side read of the August 11 en banc decision, sharpest on remedy and what happens next. The Fifth Circuit held the QPA methodology unlawful for counting ghost rates—contracted rates for services a provider never actually furnishes—and for excluding bonus and incentive payments from a benchmark the statute defines as the total maximum payment; the deflation was stark enough that providers were winning more than 80 percent of IDR arbitrations. Vacatur stood as the default APA remedy over the agencies' disruption objections, with enforcement discretion bridging the gap while QPAs are recalculated upward. Six judges dissented, and single-case air ambulance agreements stay out of the benchmark, the one issue the agencies won.

Representative Frank Pallone sent oversight letters to six IDR entities—C2C Innovative Solutions, Commence, Dane Street, EdiPhy Advisors, National Medical Reviews, and ProPeer Resources—with responses due September 24. He wants to know how they decide disputes, how often they rule claims ineligible, how frequently providers win, and how their decision makers are paid. The context is stark: a system built for 17,000 cases a year took in 2.5 million disputes in 2025, Georgetown research puts the added spending at $22 billion over four years, and two of the six rule for providers more than 90 percent of the time.

The tri-agencies announced a recertification process for the IDR entities that decide No Surprises Act disputes, testing rationale quality, capacity to keep up with volume, and conflicts of interest, with each entity's renewal subject to a five day public petition window in which plans and employers can object. An entity that fails to renew must refund fees on its pending disputes. One framing data point: a median in network rate of $86 for an hour of hospital observation time against a median IDR award of $19,985 for the same hour.

Turquoise Health dashboard data for the second quarter of 2025 shows UnitedHealth winning 67.7 percent of the disputes it initiated, though that is 21 wins across just 31 claims. The fuller picture runs the other way, providers file the overwhelming majority of disputes and win at roughly 80 percent, with one provider side firm resolving 341,866 claims at an 88.4 percent success rate.

A Proskauer team unpacks the Fifth Circuit's August 11 en banc ruling on how insurers calculate the qualifying payment amount that anchors No Surprises Act arbitration. The court excluded ghost rates, contracted rates for services a provider never actually furnishes, required inclusion of bonus and incentive payments, and preserved the exclusion of single case agreements. The practical effect is higher QPAs in dispute resolution, a benchmark shift that lands on self funded plans just as arbitration volume keeps climbing.

Segal walks through the federal IDR overhaul's next two operational steps under the No Surprises Act. Registration for the IDR Gateway, the centralized platform replacing one-off web forms, opens September 15, and sponsors who rely on a TPA need no account of their own but should confirm the TPA has registered. New batching rules take effect November 1. Up to 50 items or services may travel in one dispute if furnished within the same 30 business day window and tied to a single patient encounter or the same or comparable service code, and a batched determination now triggers a 30 business day cooling off period before the initiating party may open a new dispute over the same item or service.

HaloMD claims the No Surprises Act has cut out-of-network emergency spending by 13% to 52%, saving $1 billion to $4 billion a year. Independent researchers are skeptical. The study leans on assumptions rather than actual payment data, ignores the cost of running the arbitration system, and comes from a company that files about a quarter of all arbitration claims itself. Worth knowing before this number shows up in a policy fight.

Proskauer breaks down the en banc Fifth Circuit's August 11 decision rejecting the government's qualifying payment amount methodology under the No Surprises Act. The court held that ghost rates, meaning contracted rates for services a provider never actually furnishes, must be excluded from the QPA, that bonus and incentive payments must be included because the statute's reference to total amounts means the entire amount owed, and that one-off single-case agreements stay out. Payors should watch for agency guidance on how QPAs get recalculated.

On August 11 the en banc Fifth Circuit affirmed the district court's vacatur of key portions of the departments' qualifying payment amount methodology in Texas Medical Association v. HHS, the rules governing how plans calculate the benchmark rate that anchors No Surprises Act payment disputes. (Separately, the tri-agencies' July guidance specifying required remittance advice remark codes for No Surprises Act claims takes effect November 1, with mandatory use for items and services furnished on or after January 1, 2027.)

ERIC's read of the Georgetown research puts No Surprises Act arbitration costs at $22.4 billion over four years, with filings up 77 percent year over year and providers winning roughly 85 percent of disputes at awards well above median in-network rates. The employer lobby wants Congress to recalibrate the IDR process, arguing plans and workers ultimately absorb the pressure.

Researchers estimate that independent dispute resolution has created $22 billion in unnecessary spending. But that estimate is flawed, argue associations representing anesthesiologists, radiologists and ER doctors.

Accelerating dispute volumes and sky-high award amounts are inflating how much independent dispute resolution is costing the U.S., according to new Georgetown research. Patients could pay the price with higher premiums.

The 2026 regulations standardize claim communications, restructure open negotiation, clarify batching rules, and impose tighter deadlines for determining IDR eligibility. Self-funded plans must register.

Akerman breaks down what TMA III actually struck from the QPA methodology: ghost rates, bonus and incentive payments, and the treatment of single-case agreements, and what health plans and insurers should do while the Departments draft replacement guidance.

The Departments posted a statement confirming that the Fifth Circuit's August 11 en banc decision in Texas Medical Association v. HHS affirmed portions of a district court judgment striking certain regulations and guidance on how the qualifying payment amount is calculated. The Departments say they are reviewing the opinion and anticipate issuing guidance shortly, and that the Federal IDR process remains operational. Until that guidance issues, the QPA methodology the rules prescribed has no replacement.

The Departments released a timeline guide fixing the applicability date for each piece of the June Federal IDR Operations final rules. Two dates matter most for group health plans: the revised batching rules reach disputes whose open negotiation period begins on or after November 1, 2026, and the new remittance advice coding requirements attach to items and services furnished on or after January 1, 2027.

ArentFox Schiff calls TMA III what it is: an important but incomplete provider win. Ghost rates and the bonus exclusion are out of the QPA math, while the agencies held the line on excluding single-case agreements.

DOL's semiannual regulatory agenda, where EBSA rulemakings get sequenced. The notable thing is how empty it is: the EBSA section carries exactly one entry, the IDR Operations rule, and that rule was already finalized on June 4. In other words, EBSA currently has no pending rulemaking on the public agenda at all.

Polsinelli confirms the en banc Fifth Circuit's August 11 ruling struck the ghost-rate, out-of-specialty, and bonus-exclusion provisions of the QPA methodology, and maps what the recalculation means for payors and plans.

Healthcare Dive's news coverage of the TMA III ruling that led Friday's Digest: ghost rates and bonus exclusions are out of QPA math, and payouts to providers are set to rise.

Groom reviews CMS's newly announced updates to federal IDR operations and the dispute portal under this year's final rule, a companion read to the implementation timeline guide the Departments released last week.

Get compliance insights on the new IDR Gateway, RARC code requirements and next steps for group health plan sponsors.

The Departments of Health and Human Services, Labor, and the Treasury (Departments) recently released the Federal Independent Dispute Resolution (IDR) public use files (PUF) and supplemental tables for the third and fourth quarters of 2025.

On 5/28/26, the Departments of Health and Human Services, Labor, and the Treasury released final rules modifying the Federal independent Dispute Resolution Operations

Turquoise Health has launched a new dashboard that provides free tracking of independent dispute resolution (IDR) awards from disputes over services covered by the No Surprises Act.

It's the third recent legal victory in No Surprises lawsuits for billings intermediary HaloMD, which has also had suits dismissed in California and Texas.