Why This Case Signals a Shift in Risk and Responsibility for Plan Sponsors

A recent ruling by the Fifth Circuit in Guardian Flight v. Health Care Service Corporation sends a strong message to healthcare providers and plan sponsors alike: the courts will not step in to enforce payment of Independent Dispute Resolution (IDR) awards under the No Surprises Act (NSA). Only the federal government has that authority.

While the case involved air ambulance providers and an insurer, the implications reach much farther. For employers and self-insured health plans, this decision shifts the burden of enforcement away from the courts and deepens the importance of administrative compliance and claims defense.

The Core Legal Issue

At the center of the dispute were thirty-three IDR awards in favor of Guardian Flight and Med-Trans Corporation, both air ambulance providers, against Health Care Service Corporation (HCSC). When the providers didn’t receive payment within the 30-day deadline set by the NSA, they sued under three legal theories, direct enforcement of the NSA, a derivative ERISA claim and unjust enrichment under Texas law.

The Fifth Circuit rejected all three. Most notably, the court held that the NSA does not allow providers, or anyone else, to sue in court to enforce an IDR award. Congress will have to go back to the drawing board to create an enforcement mechanism, as none currently exists. The only enforcement mechanism in the NSA relates to complying with the consumer oriented protections, such as not requiring preauthorization for emergency visits and limiting the cost-sharing amount to the in-network rate. There is simply no discussion in the NSA about enforcement of IDR awards.

What Makes This Case Important

This decision draws a bright line, there is no private right of action under the NSA, even when an insurer fails to pay an IDR award. That leaves providers without judicial recourse and forces them to rely on administrative complaints filed through CMS (which also may not be the appropriate remedy). The court also denied the ERISA claim, finding that participants suffered no injury because the NSA shields them from liability. Without participant harm, the providers lacked standing. Finally, the court ruled that unjust enrichment didn’t apply because services were rendered for patients, not insurers.

The outcome? A complete dismissal—affirmed on appeal.

Why It Matters to Plan Sponsors

On its face, the ruling looks like a setback for providers. For plan sponsors, it creates both opportunity and risk.

The opportunity lies in reduced litigation exposure. With courts off-limits to providers, the threat of being sued over NSA payment disputes is lower. The risk is just as real. If your administrator fails to comply with NSA deadlines or mishandles IDR outcomes, enforcement could come from federal agencies. That means formal complaints, audits, and penalties, all of which can implicate your plan and trigger deeper scrutiny.

Compliance now depends on proactive oversight and the strength of your administrative partners.

How aequum Protects Plans Throughout the NSA Process

aequum helps plan sponsors navigate exactly this kind of regulatory gap. aequum’s legal partners ensure that IDR decisions are executed correctly. aequum support clients by:

• Tracking and managing all NSA-related deadlines and payment requirements.
• Coordinating with administrators to confirm compliance with or defense against IDR rulings.
• Intervening when disputes escalate or enforcement risk emerges.
• Advising on plan language and governance to withstand regulatory scrutiny.

aequum doesn’t just defend IDR outcomes, we help prevent issues before they become liabilities.

What Employers Should Do Now with aequum on Their Side

The Guardian Flight ruling closes one path. Providers can’t sue but they will report to CMS. For plan sponsors, this is the moment to assess your potential administrative exposure and reinforce your NSA processes.

aequum provides the clarity, operational discipline and strategic protection plans need in this new compliance environment. With aequum on your side, your plan isn’t just prepared, it’s protected.

Contact aequum today to learn how we help you stay ahead of NSA enforcement, defend your plan decisions and reduce your exposure to costly compliance failures.