No Private Right of Action under the No Surprises Act: Guardian Flight, L.L.C. & Med-Trans Corp. v. Health Care Service Corp.

Introduction

On 12 June 2025 the U.S. Court of Appeals for the Fifth Circuit delivered a precedential opinion in Guardian Flight, L.L.C.; Med-Trans Corp. v. Health Care Service Corporation, No. 24-10561, affirming dismissal of air-ambulance providers’ claims against an insurer for non-payment of Independent Dispute Resolution (IDR) awards issued under the No Surprises Act (NSA). The decision squarely holds that:

• The NSA contains no express or implied private right of action for providers (or anyone else) to enforce or confirm an IDR award in court.
• Providers suing derivatively under ERISA lack Article III standing when the NSA statutorily insulates plan beneficiaries from financial responsibility for the disputed bills.
• Quantum-meruit recovery under Texas law fails because emergency medical services benefit the patient, not the insurer.

In reaching these conclusions, the Fifth Circuit became the first federal appellate court to interpret the NSA’s remedial structure, effectively shifting disputes over IDR award enforcement away from the courts and toward the administrative enforcement regime supervised by the U.S. Department of Health & Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS).

Summary of the Judgment

The plaintiffs—air-ambulance providers Guardian Flight and Med-Trans—obtained 33 IDR “baseball-style” awards mandating payment from defendant Health Care Service Corp. (HCSC). When the insurer allegedly failed to pay within 30 days, the providers sued in the Northern District of Texas asserting:

1. Direct enforcement of the NSA.
2. Derivative claims for benefits under ERISA §502(a)(1)(B) based on assignments from plan members.
3. Quantum-meruit/unjust-enrichment under Texas common law.

The district court dismissed the complaint under Fed. R. Civ. P. 12(b)(1) & 12(b)(6), finding:

• No private right of action in the NSA.
• No Article III injury traceable to beneficiaries (and therefore no derivative ERISA standing).
• No direct benefit conferred on the insurer for quantum meruit.

The Fifth Circuit affirmed on all grounds. Core holding: Judicial “review” barred by the NSA includes actions to enforce or confirm IDR awards; Congress deliberately assigned enforcement to HHS, not private litigants.

Analysis

1. Precedents Cited and Their Influence

• Alexander v. Sandoval, 532 U.S. 275 (2001) – Modern template for implied-right-of-action analysis; court invokes the “express provision of one method of enforcement suggests exclusion of others” canon.
• Sigmon v. Southwest Airlines Co., 110 F.3d 1200 (5th Cir. 1997) & Casas v. American Airlines, 304 F.3d 517 (5th Cir. 2002) – Fifth Circuit authority placing a “heavy burden” on would-be private plaintiffs to show Congress “affirmatively contemplated” private enforcement.
• Hall Street Associates v. Mattel, Inc., 552 U.S. 576 (2008) and Concrete Pipe & Products, 508 U.S. 602 (1993) – Define “judicial review” under the Federal Arbitration Act (FAA) to encompass actions to confirm, vacate, or modify awards; key to the court’s conclusion that enforcement equals review.
• North Cypress Medical Center v. Cigna, 781 F.3d 182 (5th Cir. 2015) – Earlier provider-ERISA standing case distinguished because it predates the NSA’s patient-shield provisions.
• Thole v. U.S. Bank, 590 U.S. 538 (2020) & TransUnion LLC v. Ramirez, 594 U.S. 413 (2021) – Reinforce that Article III requires concrete injury; “breach of contract without harm” insufficient.
• Statutory comparators: FAA §9 (express confirmation right) vs. NSA (incorporates only FAA §10(a)’s limited vacatur grounds); differences bolster inference of no private remedy.

2. Legal Reasoning

1. Text and Structure of the NSA
   • 42 U.S.C. § 300gg-111(c)(5)(E)(i)(II) states IDR determinations “shall not be subject to judicial review” except under FAA §10(a) vacatur grounds.
   • Vacuum left by omission of FAA §9 (confirmation/enforcement) is read as intentional.
   • HHS enforcement provisions (§ 300gg-22 & § 300gg-134) signal that Congress chose an administrative, not judicial, remedy.
2. Meaning of “Judicial Review”
   • Employs Black’s Law Dictionary definition including “power to remand, modify, vacate or act directly in place of the subordinate.”
   • Supreme Court precedent under FAA treats actions to “confirm” as a subset of judicial review; therefore providers’ suit is within the statutory bar.
3. Implied Rights Doctrine
   • Applying Sandoval, the court asks whether rights-creating language exists; answer: no.
   • Legislative silence coupled with explicit prohibition indicates deliberate exclusion.
4. ERISA Standing
   • Assignment requirement met, but beneficiaries must still have suffered a concrete injury.
   • NSA’s “patient-shield” provisions (42 U.S.C. § 300gg-135) eliminate any out-of-network liability; thus no injury in fact → no standing.
5. Quantum Meruit
   • Under Texas law, services must be rendered for the defendant.
   • Providers furnished emergency transport for patients, not for HCSC; no direct benefit → claim fails.

3. Potential Impact

• Litigation Landscape: Cuts off a burgeoning wave of NSA-based lawsuits by providers seeking quick judicial enforcement of IDR awards. Expect dismissals or transfers to administrative complaint channels.
• Administrative Burden: CMS/HHS may face increased complaint volume; may necessitate additional guidance or resources to ensure timely penalty assessments and award payments.
• Insurance & Provider Negotiations: Shifts bargaining leverage—insurers gain comfort that delayed payment disputes will remain within agency oversight, while providers must weigh the cost of prolonged administrative enforcement.
• ERISA Doctrine: Clarifies that statutory shields removing beneficiary liability can defeat provider standing notwithstanding prior precedent allowing assignments.
• Split with District Courts: Creates circuit-level authority contradicting at least one district court (D. Conn. 2025) that implied a private right; heightens possibility of circuit split if other circuits disagree.

Complex Concepts Simplified

• No Surprises Act (NSA): 2022 federal law preventing patients from receiving unexpected bills when treated by out-of-network providers, especially in emergencies. Disputes between providers & insurers go to an “Independent Dispute Resolution” (IDR) process.
• IDR “Baseball-Style” Arbitration: Each side submits a dollar figure; the certified arbitrator (CIDRE) must choose one of the two numbers—encouraging reasonable offers.
• Private Right of Action: The legal ability of a private party to sue under a statute. It can be “express” (clear language) or “implied” (inferred from text, structure, purpose).
• Judicial Review vs. Enforcement: Although sometimes differentiated, courts here treat “review” broadly as any court engagement with an arbitral award—including efforts to confirm, vacate, modify, or enforce it.
• ERISA Standing via Assignment: Providers often step into beneficiaries’ shoes through assignments of plan benefits; yet they inherit only the rights and injuries of those beneficiaries.
• Quantum Meruit (Texas): Equitable doctrine allowing payment for services rendered when no contract governs, but only if the services were performed for, and benefited, the defendant.

Conclusion

The Fifth Circuit’s decision in Guardian Flight v. HCSC sets a decisive precedent: Providers cannot invoke federal courts to enforce IDR awards under the No Surprises Act; the Act’s remedial architecture vests that function in HHS/CMS and sharply limits judicial involvement to narrow FAA §10(a) vacatur scenarios. Additionally, the ruling narrows provider use of derivative ERISA suits where statutory mechanisms already shield patients, and it reaffirms Texas’ stance that quantum-meruit claims lie against patients, not insurers. Together, these holdings redirect post-IDR disputes to the administrative arena and clarify doctrinal boundaries at the intersection of the NSA, ERISA, and state unjust-enrichment law. Stakeholders—providers, payors, patients, and regulators—must adapt strategies accordingly, while observers should monitor other circuits for potential divergence that could invite Supreme Court review.