Payor-Provider Alert: District Courts Turn Away Insurer Challenges to No Surprises Act Awards, and Three Circuits Will Decide Whether the Door Stays Shut

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Anthem Blue Cross Life & Health Insurance Co. v. HaloMD LLC, No. 8:25-cv-01467-KES, 2026 WL 982629 (C.D. Cal. Apr. 9, 2026), appeal docketed, No. 26-2355 (9th Cir. Apr. 16, 2026) | Aetna Health Inc. v. Radiology Partners, Inc., No. 3:24-cv-1343-BJD-LLL (M.D. Fla. Apr. 16, 2026), appeal docketed, No. 26-11607 (11th Cir. May 8, 2026) | Blue Cross Blue Shield of Texas v. HaloMD, LLC, No. 5:25-cv-132 (E.D. Tex. May 22, 2026), appeal docketed, No. 26-40316 (5th Cir. May 27, 2026) | Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. v. HaloMD, Inc., No. 1:25-cv-02919-TWT (N.D. Ga. July 10, 2026), appeal docketed, No. 26-12777 (11th Cir. Aug. 6, 2026) | REACH Air Medical Services LLC v. Kaiser Foundation Health Plan Inc., 160 F.4th 1110 (11th Cir. Nov. 19, 2025)

Healthcare / Payor-Provider Disputes · No Surprises Act · Independent Dispute Resolution (IDR) · Vacatur

Introduction

Beginning in 2024, several large insurers sued providers and entities that assist in filing independent dispute resolution (IDR) cases on providers’ behalf under the federal No Surprises Act (NSA), alleging they flooded the process with ineligible disputes and collected awards to which they were never entitled. The insurers framed their cases in several ways: civil RICO, ERISA, state fraud and unfair-competition law, along with requested remedies to vacate the awards outright. Between April and July 2026, district courts in California, Florida, Texas and Georgia dismissed all four suits discussed here, and the insurers appealed to the Fifth, Ninth and Eleventh Circuits. The bottom line, explored in more detail below: the loser in an NSA case can’t sue to vacate the award except on the narrow grounds the NSA borrows from the Federal Arbitration Act (FAA).

Executive Summary

The NSA was intended to address the practice by out-of-network providers of balance billing their patients for the difference between their billed charges and amounts paid by the patient’s health insurer. The NSA established the IDR process, in which independent arbitrators resolve disputes between the provider and the health insurance payor, eliminating the provider’s right to balance bill the patient except for previously agreed co-pays and deductibles. The NSA requires the insurer to provide a “qualifying payment amount,” or QPA, which is essentially a median calculation of the insurer’s negotiated rates for the services at issue. After a period of negotiation, the provider and the insurer each make an offer (the insurer’s typically at or near the QPA, the provider’s typically some multiple of it), and the IDR arbitrator must choose, “baseball-style,” one of the two numbers to award.

In each of the three years for which the federal government has published full-year data, IDR entities have chosen the provider’s offer in most disputes: 81% of the time in 2023, 85% in 2024 and 85% to 88% in 2025, according to the Centers for Medicare & Medicaid Services (CMS). In light of these numbers, and other alleged practices by providers and the entities that represent them in IDR proceedings, several insurance companies have gone to court, challenging a system they argue is not working as Congress intended.

The defendants in three of the four cases addressed here are HaloMD, a Texas-based company that files IDR disputes on behalf of out-of-network providers, together with, in various combinations, its president Alla LaRoque, Scott LaRoque and his company MPOWERHealth, and physician groups that use HaloMD’s services. According to CMS, HaloMD, TeamHealth and SCP Health together accounted for about 44% of IDR disputes initiated in the first half of 2025. CMS, Supplemental Background on Federal Independent Dispute Resolution Public Use Files (January 1, 2025 – June 30, 2025). Anthem affiliates in California and Georgia and Blue Cross Blue Shield of Texas alleged that HaloMD and its clients filed disputes that were never eligible for IDR (hundreds in the California case, thousands in Georgia and more than 42,000 in Texas), covering claims already resolved, services the patient’s plan didn’t cover and similar defects, and attested to eligibility anyway. In the fourth case, Aetna alleged that Radiology Partners, a private-equity-backed aggregator of radiology practices, ran other Florida practices’ claims through the tax identification number of one acquired practice, Mori, Bean and Brooks. Aetna ended that practice’s network contract over the routing, and Radiology Partners kept it up afterward, filing tens of thousands of IDR disputes that misidentified who had performed the services.

Each district court dismissed the insurers’ claims. Across the four decisions, the courts barred the insurers’ claims on various bases, including: 1) the NSA bars judicial review of IDR determinations beyond the FAA’s vacatur grounds; 2) whether a dispute is eligible for IDR is for the IDR entity to decide; 3) fraud an insurer knew about, or had the chance to raise, during the IDR process cannot support vacatur afterward; and 4) RICO, ERISA, state-law and declaratory-judgment claims seeking the same relief are attempts to get around those limits. Not every court reached every point. The vacatur claims (in California, Florida and Georgia) failed on the merits; the other claims failed for lack of jurisdiction or, in Florida, on preemption. Three of the four dismissals were with prejudice; in the California case, the court dismissed the federal claims without leave to amend and declined to exercise supplemental jurisdiction over the state-law claims, dismissing them without prejudice. All four insurers have appealed to their respective circuits. None of the appeals has yet been argued.

Background

Providers Prevail in the Majority of IDR Proceedings

The outcomes of the IDR process have run heavily one way. In the second half of 2025, providers, facilities and air ambulance providers were the prevailing party in about 85% of payment determinations, down from 88% in the first half of the year, and the prevailing offer exceeded the QPA in about 87% of determinations. CMS, Supplemental Background on Federal Independent Dispute Resolution Public Use Files (July 1, 2025 – December 31, 2025). Researchers at Georgetown University’s Center on Health Insurance Reforms, analyzing CMS data, put the provider share at 81% in 2023 and 85% in 2024. Jack Hoadley, Kennah Watts, Katie Keith & Ellie DeGarmo, The No Surprises Act IDR Process: An Early Look at 2025 Data, Health Affairs Forefront (Mar. 2026). A “win” means the IDR entity chose the provider’s offer, not that the provider received any particular amount, and a small number of high-volume filers account for much of the volume. That record is the backdrop for the suits discussed here. The insurers read it as evidence that the process is being gamed; providers read it as evidence that plans’ QPAs are routinely understated.

Why providers prevail so often is itself disputed. Researchers at the Brookings Institution offered several possible explanations: providers may take their strongest claims to IDR and settle the rest; IDR entities may give weight to the higher out-of-network amounts plans paid before the NSA, which the median awards resembled more closely than in-network rates; plans’ QPAs may understate actual in-network rates; and after courts set aside the agencies’ rules directing IDR entities to give the QPA special weight, IDR entities had little substantive guidance. Matthew Fiedler & Loren Adler, A First Look at Outcomes Under the No Surprises Act Arbitration Process, Brookings Institution (Mar. 27, 2024). Others look at the IDR entities themselves. Researchers at Georgetown University’s Center on Health Insurance Reforms found that provider win rates ranged from 19% to 99% depending on the IDR entity, and raised concerns about fee incentives and the absence of written reasons. Kennah Watts & Jack Hoadley, No Surprises Act Arbitrators Vary Significantly In Their Decision Making Patterns, Health Affairs Forefront (June 24, 2025). Paragon Health Institute, a market-oriented health policy group, reported that IDR entities handling more disputes tend to favor providers more often, and noted that “[a]rbitrators are not paid until they award disputes.” Jackson Hammond & Katherine Hall, Fixing the No Surprises Act: Scaling Back and Reforming the Federal Arbitration System, Paragon Health Institute (Sept. 14, 2026). Provider groups read the record differently. In an analysis sent to Congress, the American College of Emergency Physicians, the American College of Radiology and the American Society of Anesthesiologists said that insurers lost about a quarter of 2025 line items by default and offered $1 or less on 8.2%, and argued that “the QPA is unreliable, fundamentally flawed, and used by insurers to game the system.” Insurers Are Undermining the No Surprises Act, Then Claiming IDR Process Is Broken, New Analysis Sent to Congress Explains, ACEP Now (Oct. 1, 2026).

The NSA Provides Limited Review for the Results of the IDR Process

The NSA makes an IDR entity’s payment determination “binding upon the parties involved, in the absence of a fraudulent claim or evidence of misrepresentation of facts presented to the IDR entity involved regarding such claim,” and provides that it “shall not be subject to judicial review, except in a case described in any of paragraphs (1) through (4) of section 10(a) of title 9.” 42 U.S.C. § 300gg-111(c)(5)(E)(i); 29 U.S.C. § 1185e(c)(5)(E)(i). Those are the FAA’s grounds for vacating an arbitration award: corruption, fraud or undue means; evident partiality or corruption in the arbitrator; specified misconduct; and an arbitrator exceeding its powers. 9 U.S.C. § 10(a)(1)–(4).

The Eleventh Circuit has held that this cross-reference imports the FAA’s existing case law. REACH Air Medical Services LLC v. Kaiser Foundation Health Plan Inc., 160 F.4th 1110, 2025 WL 3222820, at *4 (11th Cir. Nov. 19, 2025). Under that FAA case law, a party seeking to vacate an award for fraud must prove it by clear and convincing evidence, show that it couldn’t have been discovered with due diligence before or during the arbitration, and show that it related materially to an issue in the arbitration. Id. at *6. REACH came from the provider side: an air-ambulance company challenged an award Kaiser won, alleging Kaiser had given the IDR entity a lower QPA than it had given the provider, and the Eleventh Circuit affirmed dismissal. The Florida court applied REACH directly, and the California court applied the same test from Ninth Circuit precedent.

Contested Eligibility Decisions

Not every out-of-network claim qualifies for IDR. Before an IDR entity picks between the parties’ offers, federal regulations require it to determine that the dispute is eligible. 45 C.F.R. § 149.510(c)(1)(v). The insurers’ core theory is that this screening has failed at scale and that high-volume filers have taken advantage of it. In the Texas case, the defendants answered with the government’s own figures: in 2024, non-initiating parties objected to eligibility in 44% of disputes, but only 19% were found ineligible. Blue Cross Blue Shield of Texas, slip op. at 5. The providers’ answer on the law, which the courts have so far accepted, is that the eligibility decision is part of the IDR entity’s determination, and therefore inside the NSA’s limit on judicial review. As the California court put it, “An IDRE’s payment determination necessarily includes a determination of eligibility.” Anthem, 2026 WL 982629, at *9.

Providers’ Avenues for Review Are Also Limited

Two circuits have addressed the reverse posture: a provider holding an unpaid award. East Coast Advanced Plastic Surgery, LLC v. Cigna Health & Life Insurance Co., No. 25-2204, ___ F.4th ___ (2d Cir. Sept. 17, 2026) (ECAPS); Guardian Flight, L.L.C. v. Health Care Service Corp., 140 F.4th 271 (5th Cir. 2025), cert. denied, No. 25-441 (U.S. Jan. 12, 2026). Both courts held that the NSA creates no private right of action to enforce an award, and that enforcement is left to the Department of Labor, the Department of the Treasury, the Department of Health and Human Services and state insurance regulators. The Fifth Circuit went further and held that the NSA’s limit on judicial review bars suits to confirm IDR awards; the Second Circuit left that question open. The Supreme Court denied review in Guardian Flight in January 2026. We discussed ECAPS in an earlier Case Spotlight.

The District Court Decisions

Anthem Blue Cross Life & Health Insurance Co. v. HaloMD LLC, 2026 WL 982629 (C.D. Cal. Apr. 9, 2026). Anthem asserted RICO, a claim to vacate under the NSA, an ERISA claim under 29 U.S.C. § 1132(a)(3), declaratory relief and California law. The district court dismissed the vacatur claim because Anthem knew of the alleged false eligibility attestations and objected to them during the IDR process, so the fraud was not undiscoverable; adopting one group of defendants’ phrase, the court said that “Anthem has pleaded itself out of court.” Id. at *8. The court also held that the fee structure Congress built into the IDR process is not “undue means,” and that because IDR entities are authorized to decide eligibility, the claim that they exceeded their powers collapsed into the fraud claim. Id. It dismissed the RICO, ERISA and declaratory claims for lack of subject-matter jurisdiction: “These theories are all end runs around the NSA’s limits on judicial review.” Id. at *10. It declined supplemental jurisdiction over the state-law claims, dismissing them without prejudice, and denied leave to amend. Id. at *10–11.
Aetna Health Inc. v. Radiology Partners, Inc. (M.D. Fla. Apr. 16, 2026). Aetna sought to vacate the awards and recover arbitration fees and overpayments. In one example the court described, an IDR entity awarded $752.00 on a claim whose in-network rate was $78.89. Id., slip op. at 7. The district court found that Aetna had pleaded fraud with the particularity Rule 9(b) requires. But applying REACH, it held that the fraud was discoverable with due diligence before the IDR proceedings, because Aetna had terminated the practice’s network contract over the same conduct. The court called it “a close call,” but held that Aetna’s admission that it ended the contract over that conduct was “fatal to Aetna’s position,” and that neither the volume of claims nor the defendants’ efforts to conceal the scheme could “excuse Aetna’s failure to raise the issue in the IDR disputes.” Id. at 8–9. It also declined to screen disputes that hadn’t yet been filed, noting that Aetna can challenge them before the IDR entity. It treated the remaining claims as an attempt to “end-around the NSA and FAA strictures,” held them preempted, and dismissed with prejudice. Id. at 9–10.
Blue Cross Blue Shield of Texas v. HaloMD, LLC (E.D. Tex. May 22, 2026). Blue Cross Blue Shield of Texas alleged that HaloMD, Alla LaRoque and Scott LaRoque used more than 42,000 ineligible IDR disputes, under both the federal process and Texas’s own arbitration process, to obtain tens of millions of dollars in awards. The district court held that the NSA’s bar on review of payment determinations extends to eligibility decisions and that the suit was an impermissible collateral attack on the awards, observing that the plaintiff “is attempting to relitigate issues previously decided by the IDR entities.” Id., slip op. at 11. It reached the same result for the disputes under Texas’s own arbitration statute, and dismissed every claim with prejudice for lack of subject-matter jurisdiction. Id. at 14–18.
Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. v. HaloMD, Inc. (N.D. Ga. July 10, 2026). The Georgia plan alleged that HaloMD and two Georgia physician groups that are HaloMD clients submitted thousands of ineligible disputes, and asserted RICO, ERISA and Georgia-law claims along with a claim to vacate the awards. The district court held that it lacked jurisdiction over every claim except vacatur, because each would require it to re-examine eligibility and payment decisions the IDR entities had already made. It dismissed the vacatur claim on the merits: the fraud allegations didn’t meet Rule 9(b), in part because the plan had the opportunity to object before the IDR entities; nothing alleged rose to “undue means”; and IDR entities that decide eligibility don’t exceed their powers. It also found no personal jurisdiction over HaloMD. Responding to the plan’s point that providers prevail in 85% of payment determinations, the court wrote that it was “highly improbable” to infer a conspiracy of providers and IDR entities from those numbers, and “highly plausible to infer that the Plaintiff engages in a consistent practice of submitting lowball offers to out-of-network providers in an effort to maximize its profits.” Id., slip op. at 62. It dismissed the case with prejudice.

Legal Analysis

Eligibility belongs to the IDR entity. The California, Georgia and Texas courts each treated the eligibility decision as part of the IDR determination rather than a separate question a court can revisit. (The Florida court didn’t need to reach it.) That reading matters because nearly every insurer theory, whatever its label, depends on showing that particular disputes should never have reached IDR. The California court noted the consequence of the contrary view: “nearly every eligibility determination disputed by an IDR participant would be subject to review.” Anthem, 2026 WL 982629, at *8.
Fraud known during the IDR process cannot support vacatur afterward. The FAA’s fraud ground requires fraud that could not have been discovered through due diligence. In the California, Florida and Georgia cases, the insurers’ own allegations showed that they knew of the conduct before or during the IDR proceedings. In California, they objected to it, and in Georgia they had the chance to. The Florida court’s message was that an insurer with evidence of ineligibility or misrepresentation must raise it in the IDR dispute, not hold it for later litigation.
Relabeling the claim does not change the analysis. RICO, ERISA, declaratory-judgment and state-law claims all sought to recover or nullify IDR awards. The courts treated them as attempts to obtain the judicial review the NSA does not allow. California, Georgia and Texas framed the result as a lack of jurisdiction, with Georgia and Texas calling the claims collateral attacks on the awards; Florida framed it as preemption of claims resting on the same facts. California didn’t reach the state-law claims, dismissing them without prejudice.
The insurers’ position on appeal. The insurers argue that the courts have read the judicial-review limit to cover conduct outside the arbitration itself, leaving no forum for what they describe as systematic abuse of the process. Elevance said after the Georgia ruling that the decision “misinterprets the No Surprises Act and improperly limits judicial review.” Health plan and employer groups — America’s Health Insurance Plans; the American Benefits Council, the ERISA Industry Committee and the Business Group on Health; and the California Association of Health Plans and the Association of California Life & Health Insurance Companies — have filed amicus briefs supporting Anthem in the Ninth Circuit. The providers respond that Congress chose a closed, arbitration-based process with limited review, and that the FAA’s vacatur grounds and agency oversight are the remedies it provided.

What to Watch

The Eleventh Circuit, twice. Aetna v. Radiology Partners, No. 26-11607, will be fully briefed when Aetna files its reply, due October 14, 2026, and Blue Cross Blue Shield of Georgia v. HaloMD, No. 26-12777, is at an earlier stage: the Georgia plan’s opening brief is due October 15, 2026. Both will be decided against the court’s own REACH decision, which supplied the vacatur standard the Florida court applied.
The Ninth Circuit, without an NSA precedent. Anthem v. HaloMD, No. 26-2355, comes to a court that hasn’t yet ruled on IDR review, with health plan and employer amici already filed, although the district court found the vacatur claim controlled by the Ninth Circuit’s existing FAA case law. Anthem filed its opening brief on August 5, 2026, the defendants filed their answering briefs on October 5, and Anthem’s optional reply is due November 27, 2026. It is the most likely source of a different answer.
The Fifth Circuit, against Guardian Flight. Blue Cross Blue Shield of Texas v. HaloMD, No. 26-40316, will be decided by the court that held the NSA’s limit on judicial review bars suits to confirm IDR awards. How that court applies the same limit to an insurer seeking to undo awards will be worth watching.
Timing. No argument dates have been set in any of the four appeals. Decisions before spring 2027 would be unusual. A circuit split on insurer challenges would raise a question about the IDR process that the Supreme Court has so far declined to take up from the provider side.

What This Means for Resolving Payor-Provider Disputes

If the circuits affirm, the IDR award becomes close to final in both directions: hard for the losing insurer to undo and, after ECAPS and Guardian Flight, hard for the winning provider to collect through a lawsuit. The courts’ emphasis on raising eligibility and misrepresentation objections inside the IDR proceeding also moves the real contest earlier, into the dispute itself, where each side’s record is made.

For parties with disputes running in both directions — unpaid awards on one side, claimed overpayments and ineligible filings on the other — litigation offers neither side a clean path. That tends to push the numbers toward negotiation, often across a portfolio of claims rather than one dispute at a time. The awards themselves still matter there: each one is a neutral’s answer to what a set of services was worth, and a large body of them gives both sides a shared reference point for resolving the rest.

John Libby is an arbitrator, mediator, and settlement counsel with LibbyADR LLC. This post contains his own summaries of the decisions discussed, prepared for general informational purposes only. The summaries are not intended to be a complete statement of any court’s reasoning, nor should they be taken to indicate how he would rule as an arbitrator in any particular case. In addition, the summaries are not legal advice, nor should they be construed as legal advice. Readers should not act on these posts, but should review the decisions themselves and consult with legal counsel.