Consolidating Judicial Review under the No Surprises Act: Fifth Circuit Confirms Exclusive FAA Grounds and Extends Arbitral Immunity to Certified IDR Entities

Introduction

Guardian Flight, L.L.C. v. Medical Evaluators of Texas ASO, L.L.C. (consolidated with Guardian Flight, L.L.C. v. Aetna Health, Inc. and Kaiser Foundation Health Plan, Inc.), decided by the United States Court of Appeals for the Fifth Circuit on 12 June 2025, addresses two pivotal questions circulating since the enactment of the No Surprises Act (NSA):

• Whether emergency air-ambulance providers possess a private right of action to vacate Independent Dispute Resolution (IDR) payment determinations beyond the narrow grounds enumerated in § 10(a) of the Federal Arbitration Act (FAA); and
• Whether Certified Independent Dispute Resolution Entities (CIDREs) enjoy arbitral immunity when sued for their conduct in rendering IDR awards.

The appellants—Guardian Flight, Reach Air Medical Services (REACH), and Calstar Air Medical Services (CALSTAR) (collectively, “Providers”)—challenged payment awards secured by insurers Aetna Health, Inc. (Aetna) and Kaiser Foundation Health Plan, Inc. (Kaiser). Providers further sued Medical Evaluators of Texas (MET), the CIDRE that issued the awards, for alleged misconduct during the IDR process. The district court dismissed the claims against the insurers but denied MET’s assertion of arbitral immunity. On appeal, the Fifth Circuit affirmed dismissal of the claims against Aetna and Kaiser and reversed the denial of immunity, creating an important precedent for all stakeholders operating under the NSA.

Summary of the Judgment

1. No Private Right Outside FAA § 10(a): Echoing its simultaneously released opinion in Guardian Flight I, the court held that 42 U.S.C. § 300gg-111(c)(5)(E)(i)—which states that an IDR award is “binding … in the absence of a fraudulent claim or evidence of misrepresentation”—does not create an independent private right to judicially vacate awards. Instead, Congress expressly incorporated the FAA’s narrow review grounds (§ 10(a)(1)–(4)).

2. Pleading Fraud or Undue Means Under FAA § 10(a)(1): Providers’ allegations that Aetna and Kaiser misrepresented their Qualifying Payment Amounts (QPAs) and withheld calculation methodologies were held insufficient under Rule 9(b) and the high “intentional malfeasance” standard for vacatur. Speculation or inadvertent mistakes are inadequate.

3. Arbitral Immunity Extended to CIDREs: Applying the functional approach to quasi-judicial immunity, the Fifth Circuit recognized CIDREs as the equivalent of arbitrators for purposes of immunity. Accordingly, MET may not be sued for its quasi-judicial acts in rendering IDR awards.

Analysis

Precedents Cited and Their Significance

• Guardian Flight, L.L.C. v. HCSC (“Guardian Flight I”, 5th Cir. 2025): Established that the NSA incorporates the FAA’s review provisions and affords no broader private right of action. The present case adopts and applies that reasoning.
• Texas Medical Association v. HHS, 110 F.4th 762 (5th Cir. 2024): Offered a comprehensive exposition of the NSA and its IDR scheme, providing statutory context for the present dispute.
• FAA Authorities: Hall St. Assocs. v. Mattel (U.S. 2008), AT&T Mobility v. Concepcion (U.S. 2011), Trans Chem v. CNMC (5th Cir. 1998), among others—supply definitions for “fraud,” “undue means,” and the policy favoring narrow arbitral review.
• Arbitral Immunity Cases: New England Cleaning Servs. v. AAA (1st Cir. 1999), Olson v. NASD (8th Cir. 1996), and Cleavinger v. Saxner (U.S. 1985) underpin the functional test for quasi-judicial immunity.

Legal Reasoning

1. Statutory Interpretation of the NSA

The court’s linchpin is § 300gg-111(c)(5)(E)(i)(II), which flatly states IDR determinations “shall not be subject to judicial review, except” for the four FAA vacatur/modification grounds. Under the canon of expressio unius est exclusio alterius, Congress’s explicit incorporation of FAA § 10(a) implies the exclusion of any broader review. The court rejected providers’ attempt to distinguish “vacatur” from “review,” noting both are forms of post-award judicial scrutiny.

2. Heightened Pleading Standard for Fraud

Because providers invoked FAA § 10(a)(1) (fraud/undue means), Rule 9(b)’s particularity requirement applied. The court synthesized multiple circuit precedents to reiterate that:

• Fraud under the FAA demands intentional deceit or bad-faith conduct akin to bribery, bias, or deliberate destruction/concealment of evidence.
• Mere inaccuracies or calculation disagreements—even when material—do not equate to fraud or undue means.

Providers’ allegations that insurers “failed to explain” or “offered differing numbers” lacked specific facts demonstrating intent, willfulness, or an illicit scheme, and were therefore dismissed.

3. Extension of Arbitral Immunity

Although the NSA does not label CIDREs as “arbitrators,” their function—neutral adjudication of payment disputes—mirrors classic arbitration. Following Supreme Court precedent (Cleavinger), immunity revolves around function, not nomenclature. Granting immunity shields CIDREs from retaliatory litigation and preserves the efficiency Congress sought in the NSA’s streamlined IDR process.

Impact of the Judgment

• Providers & Insurers: Parties must confine any challenges to IDR awards to the four FAA grounds and satisfy Rule 9(b) where fraud is asserted. Parties cannot sue CIDREs for damages relating to their decisional acts.
• CIDRE Operations: Immunity lowers litigation risk, encouraging entities to serve as arbitrators in NSA disputes without fear of personal liability.
• Federal Courts: The opinion curtails forum shopping and reduces caseload pressures by funneling most disputes back into the administrative remand channel rather than fresh civil actions.
• Policy Landscape: The decision solidifies the NSA’s balance: robust patient protections coupled with an expeditious, arbitration-like payment resolution mechanism guarded from extensive judicial meddling.

Complex Concepts Simplified

• No Surprises Act (NSA): Federal statute shielding patients from unexpected out-of-network medical bills and establishing a binding IDR scheme for payment disputes.
• Independent Dispute Resolution (IDR): A baseball-style arbitration: each side submits a payment amount and the neutral selects one.
• Certified Independent Dispute Resolution Entity (CIDRE): A government-approved third party that conducts IDRs.
• Qualifying Payment Amount (QPA): The median in-network rate for a service, serving as a benchmark during IDR.
• Federal Arbitration Act (FAA) § 10(a): Enumerates four narrow circumstances—fraud/corruption, evident partiality, arbitrator misconduct, and overreach—in which federal courts may vacate arbitration awards.
• Vacatur: Judicial nullification of an arbitration award, typically followed by a remand for new proceedings.
• Arbitral Immunity: A doctrine insulating neutrals from suit for acts within the scope of their decision-making function, akin to judicial immunity.

Conclusion

The Fifth Circuit’s decision crystallizes two critical pillars in the post-NSA legal architecture:

1. The only pathway to judicial interference with an IDR award is via the well-trodden, tightly confined openings of FAA § 10(a). Creative re-labelling of claims as “vacatur” or “re-arbitration” cannot circumvent Congress’s explicit limitation on review.
2. CIDREs are functionally arbitrators and, therefore, are cloaked in arbitral immunity. Suits against them for performing their quasi-judicial duties are barred.

Collectively, these holdings fortify the NSA’s regimented scheme, promising greater predictability for insurers, providers, and neutrals alike, while safeguarding the statute's central mission—protecting patients from surprise medical bills without entangling courts in routine payment skirmishes.