On September 17, 2026, the Second Circuit handed down a significant decision for self-insured group health plans, holding that the No Surprises Act (“NSA”) does not create a private right of action for out-of-network providers to enforce payment awards obtained through the independent dispute resolution (“IDR”) process. The ruling in East Coast Advanced Plastic Surgery, LLC v. Cigna Health and Life Insurance Company, No. 25-2204 (2d Cir. Sept. 17, 2026), joins the Fifth Circuit’s decision in Guardian Flight, L.L.C. v. Health Care Service Corp. to resolve the question: when a provider wins an IDR award and the plan doesn’t pay, can the provider go to court to collect? Now at least in the Second and Fifth Circuits, the answer is no.
East Coast Advanced Plastic Surgery (“ECAPS”), an out-of-network provider, won more than $3 million in IDR awards against Cigna, which Cigna did not pay. ECAPS sued in federal court, seeking a declaration that Cigna owed the award amounts and had violated the NSA by failing to pay. The district court dismissed the complaint, and the Second Circuit affirmed.
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This decision arrives against the backdrop of rapidly escalating IDR costs for self-insured group health plans (discussed in previous posts here and here). Providers are prevailing in approximately 86% of IDR cases, and the median IDR award in 2024 was approximately 450% of the typical in-network rate. In 2025 alone, disputing parties initiated approximately 2.6 million disputes through the Federal IDR portal. Self-insured plans were the named non-initiating party in roughly 68% of those disputes. The financial stakes for group health plans are significant.
Against this backdrop, the Second Circuit’s ruling is a meaningful development for plan sponsors and their fiduciaries. Although IDR awards remain “binding upon the parties” under the statute, the Second and Fifth Circuits (encompassing Texas, Louisiana, Mississippi, New York, Connecticut, and Vermont), along with a number of other district courts, have now held that providers cannot march into court in these jurisdictions to enforce an award they believe was wrongly unpaid. Instead, in those jurisdictions, enforcement must be sought through DOL, Treasury, HHS, or state regulators. For plans that believe they have legitimate grounds to dispute the validity of an IDR award, for example, where an amount was awarded despite the ineligibility of the claim under the NSA and the IDR process, the ruling provides some breathing room in jurisdictions that have adopted this position. Plans should not, however, assume that declining to pay awards will go unaddressed by regulators indefinitely.
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Understand the enforcement landscape. The Second Circuit’s decision does not mean that IDR awards are unenforceable. It means that, in the Second and Fifth Circuits and in district court jurisdictions that have followed suit in other circuits, enforcement runs through administrative channels, not private litigation. Where courts in other jurisdictions have found that the NSA does create a private right of action (currently, only in the District of Maryland), or in jurisdictions that have not yet made a decision on the issue, providers may still pursue enforcement through the courts. Plans should be aware that the DOL, Treasury, and HHS retain enforcement authority in all jurisdictions and can take action against plans that fail to pay.
Continue to monitor IDR exposure. Even in jurisdictions where private enforcement lawsuits have been foreclosed, the IDR process continues to produce outsized outcomes that flow directly to plan costs. Plans should ask third party administrators for plan-specific IDR reporting and build IDR outcomes into ongoing claims experience forecasting.
Evaluate your options carefully. If your plan has grounds to challenge specific IDR awards, particularly where the third party administrator believes a claim is ineligible or a provider engaged in fraudulent or improper billing, this decision may provide additional time and flexibility to evaluate your options. However, any decision to delay or withhold payment of an IDR award should be made in close consultation with legal counsel, as regulatory enforcement remains available, regardless of jurisdiction.