REACH Air Medical v. Kaiser: FAA-Style Deference and Narrow Judicial Review of No Surprises Act IDR Awards

I. Introduction

The Eleventh Circuit’s published decision in REACH Air Medical Services LLC v. Kaiser Foundation Health Plan Inc., No. 24-10135 (11th Cir. Nov. 19, 2025), is one of the first appellate opinions to squarely address the scope of judicial review over arbitration awards issued under the federal No Surprises Act (NSA) independent dispute resolution (IDR) process, particularly in the context of air ambulance billing disputes.

The case arises from a familiar modern problem: out-of-network emergency medical services, very high charges, and a payor-provider disagreement over how much is owed. Congress enacted the NSA to protect patients from “surprise billing” and to push providers and health plans into a streamlined arbitration mechanism—the IDR process—to resolve payment disputes. This decision clarifies how tightly the courts will cabin their review of those IDR outcomes.

The parties are:

REACH Air Medical Services LLC (“Reach”) – an out-of-network air ambulance provider that transported a Kaiser enrollee.
Kaiser Foundation Health Plan Inc. (“Kaiser”) – the patient’s health plan (an HMO).
C2C Innovative Solutions, Inc. (“C2C”) – the certified IDR entity (arbitrator) that decided the payment dispute under the NSA’s baseball-style arbitration process.

After Kaiser paid Reach approximately $24,813 for an 80-mile emergency helicopter transport, the parties failed to agree on the appropriate reimbursement. They proceeded into the NSA IDR process, each submitting a proposed payment amount and supporting explanation. Kaiser submitted the same dollar amount as it had paid Reach, but it described a lower “Qualifying Payment Amount” (QPA) during IDR than it had represented to Reach on its Explanation of Benefits (EOB).

When C2C selected Kaiser’s offer, Reach moved to federal court seeking to vacate the IDR award. Reach alleged that Kaiser’s inconsistent QPA representations amounted to fraud or “undue means” under the Federal Arbitration Act (FAA) and that C2C had exceeded its authority by allegedly applying an “illegal presumption” in favor of Kaiser’s QPA. The district court dismissed the complaint. Reach appealed.

The Eleventh Circuit’s opinion does several important things:

It holds that the NSA fully incorporates the FAA’s limited grounds for vacating arbitration awards, as interpreted by prior case law, and that nothing in the NSA expands judicial review beyond FAA § 10(a)(1)-(4).
It applies that narrow standard to reject Reach’s arguments that the arbitrator exceeded its powers or that the award was procured by fraud or “undue means.”
It emphasizes the heightened pleading standard of Rule 9(b) for fraud-based challenges to IDR awards.
It confirms that parties challenging IDR awards need not name the IDR entity as a defendant in order to obtain vacatur and a remand for a new arbitration.

Collectively, the decision sends a strong message: NSA IDR awards will be treated with the same extreme deference that federal courts apply to conventional FAA arbitration awards. Allegations of misreported QPAs or dissatisfaction with the arbitrator’s reasoning will almost never suffice to vacate an award.

II. Summary of the Opinion

A. Factual Background

On February 7, 2022, a Kaiser enrollee required emergency air transport from Santa Rosa to Redwood City, California. Reach, an out-of-network air ambulance provider, performed the transport and provided continuous medical care during the 80-mile helicopter flight.

Because Reach was not in Kaiser’s network, there was no pre-negotiated contract rate. Kaiser paid Reach $24,813.48 and, in its Explanation of Benefits, represented that this amount was its Qualifying Payment Amount (QPA)—a statutory term under the NSA referring (roughly) to the median in-network rate that a health plan pays for a given service.

Unhappy with the payment level, Reach initiated the NSA’s required open negotiation period. That failed, and the parties commenced the NSA’s Independent Dispute Resolution process. They could not agree on an arbitrator and were assigned a certified IDR entity, C2C.

During IDR:

Kaiser submitted a payment offer of $24,813.48 and told C2C that its QPA was $17,304.29—lower than the QPA figure implied in the EOB sent to Reach.
Reach submitted a payment offer of $52,474.60.

Under the NSA’s “baseball-style” arbitration, the arbitrator must choose one of the two offers; it cannot split the difference or choose a third value. After reviewing submissions, C2C selected Kaiser’s offer. Its written determination stated that it considered the QPA and other statutorily required factors and concluded that Kaiser’s offer “best represents the value of the services at issue” and that the evidence did “not support the allowance of payment at a higher out-of-network rate.”

B. District Court Proceedings

Reach sued Kaiser and C2C in the Middle District of Florida, seeking vacatur of the IDR award and a remand for C2C to rehear the case. Reach alleged:

Kaiser had engaged in fraud and undue means by misstating the QPA to Reach and then to C2C.
C2C had exceeded its authority by allegedly applying an illegal presumption in favor of the QPA.
The NSA created a cause of action under which IDR entities themselves could be sued for violating the statute or regulations.

The district court:

Held that judicial review of NSA IDR determinations is restricted to the grounds in FAA § 10(a)(1)–(4).
Found Reach had failed to plead fraud or undue means with particularity under Rule 9(b).
Dismissed the complaint against Kaiser without prejudice and against C2C with prejudice, holding (among other things) that Congress had not created a cause of action against IDR entities.
Granted Reach leave to amend, but Reach chose to stand on its complaint, leading to final judgment and this appeal.

C. Issues on Appeal

Reach advanced three principal arguments on appeal:

Exceeding authority: C2C allegedly exceeded its authority under FAA § 10(a)(4) by applying an “illegal presumption” favoring Kaiser’s QPA.
Fraud / undue means: Kaiser’s inconsistent QPA submissions allegedly amounted to “fraud” or “undue means” justifying vacatur under FAA § 10(a)(1), and/or under the NSA’s language about “fraudulent claims” and “misrepresentation of facts.”
Liability of IDR entities: Reach argued that NSA IDR entities like C2C may be sued under the NSA for how they conduct arbitrations.

D. The Eleventh Circuit’s Holdings

The Eleventh Circuit affirmed the district court in full, holding that:

NSA incorporates the FAA’s limited review standards as already interpreted by courts. The phrase in 42 U.S.C. § 300gg-111(c)(5)(E)(i)(II) that IDR determinations “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” imports the FAA’s established jurisprudence, not a fresh or expanded standard.
The arbitrator did not exceed its authority. There was no plausible allegation that C2C ignored the statute, invented its own rules, or applied any unlawful presumption. At most, Reach disagreed with the arbitrator’s evaluation of the evidence and its choice between the two offers—matters insulated from judicial review.
Fraud was not pled with particularity and was not plausibly shown. Reach’s complaint did not satisfy Rule 9(b)’s particularity requirements nor the three-part test for arbitral fraud from Bonar v. Dean Witter Reynolds. The allegations failed to specify the “who, what, when, where, and how” of any fraudulent statements, failed to show that Reach was misled or relied on the statements, and failed to connect any fraud to the outcome.
“Undue means” was not plausibly alleged. Drawing on the approach of other circuits, “undue means” is limited to misconduct equivalent in gravity to corruption or fraud (e.g., physical threats or serious improper influence). Kaiser’s submission of a lower QPA figure during IDR did not approach this threshold.
C2C need not (and arguably cannot) be sued as a defendant. The court agreed that an IDR entity need not be named as a party in order for a district court to vacate an award and remand to the arbitrator for a new proceeding. Because vacatur was unwarranted, and because C2C had already been dismissed with prejudice, the court affirmed the dismissal of C2C without definitively deciding whether the NSA creates any cause of action against certified IDR entities.

III. Precedents and Authorities Cited

A. Pleading and Motion to Dismiss Standards

At the threshold, the court applied ordinary federal pleading rules for Rule 12(b)(6) dismissals. It relied on:

Smith v. United States, 873 F.3d 1348 (11th Cir. 2017), and Montgomery County Commission v. Federal Housing Finance Agency, 776 F.3d 1247 (11th Cir. 2015): these cases confirm that, on a motion to dismiss, courts accept well-pleaded factual allegations as true and draw reasonable inferences in the plaintiff’s favor.
Pedro v. Equifax, Inc., 868 F.3d 1275 (11th Cir. 2017), and Feldman v. American Dawn, Inc., 849 F.3d 1333 (11th Cir. 2017): these establish that a plaintiff must plead a claim that is “plausible on its face,” and bare legal conclusions or conclusory allegations are insufficient.
Omnipol, A.S. v. Multinational Defense Services, LLC, 32 F.4th 1298 (11th Cir. 2022); Mizzaro v. Home Depot, Inc., 544 F.3d 1230 (11th Cir. 2008); Ziemba v. Cascade International, Inc., 256 F.3d 1194 (11th Cir. 2001): these cases explain that fraud must be pled with particularity under Rule 9(b), specifying the “who, what, when, where, and how” of the alleged misconduct.
FindWhat Investor Group v. FindWhat.com, 658 F.3d 1282 (11th Cir. 2011), and Corsello v. Lincare, Inc., 428 F.3d 1008 (11th Cir. 2005): these articulate the four-part detail required by Rule 9(b) and confirm that failure to meet that standard is grounds for dismissal.

These authorities underpin the court’s insistence that Reach specify the content, timing, medium, speaker, and effect of Kaiser’s alleged misrepresentations—something the complaint never adequately did.

B. Statutory Interpretation and Incorporation of the FAA

The core statutory question was how to read the NSA’s cross-reference to FAA § 10(a). The Eleventh Circuit drew on several Supreme Court and circuit precedents:

United States v. Florida, 938 F.3d 1221 (11th Cir. 2019) (quoting Lorillard v. Pons, 434 U.S. 575 (1978)): when Congress enacts a new statute that incorporates language from an existing statute, courts presume Congress knew and accepted the existing judicial constructions of that language.
Lorillard v. Pons, 434 U.S. 575 (1978): when Congress borrows language from an earlier statute, it usually also adopts the established judicial interpretations of that language.
Bragdon v. Abbott, 524 U.S. 624 (1998), and Assa’ad v. U.S. Attorney General, 332 F.3d 1321 (11th Cir. 2003): repetition of statutory language “indicates, as a general matter, the intent to incorporate its administrative and judicial interpretations as well.”
Georgia v. Public.Resource.Org, Inc., 590 U.S. 255 (2020), quoting Helsinn Healthcare S.A. v. Teva Pharmaceuticals USA, Inc., 139 S. Ct. 628 (2019): when Congress adopts language used in an earlier act, courts presume it also adopts the existing construction of such language.

Applied here, those principles mean that when Congress provided, in 42 U.S.C. § 300gg-111(c)(5)(E)(i)(II), that IDR determinations are reviewable only “in a case described in any of paragraphs (1) through (4) of section 10(a) of Title 9,” it imported the existing body of law interpreting FAA § 10(a), rather than inviting courts to reinvent or expand those standards in the NSA context.

C. FAA Arbitration Standards and Deferential Review

The Eleventh Circuit anchored its approach in longstanding FAA arbitration jurisprudence:

Oxford Health Plans LLC v. Sutter, 569 U.S. 564 (2013), and First Options of Chicago, Inc. v. Kaplan, 514 U.S. 938 (1995): courts may vacate arbitral decisions “only in very unusual circumstances.” There is a strong presumption in favor of confirming arbitration awards.
Frazier v. CitiFinancial Corp., LLC, 604 F.3d 1313 (11th Cir. 2010), citing B.L. Harbert International, LLC v. Hercules Steel Co., 441 F.3d 905 (11th Cir. 2006): federal courts must defer to arbitrators whenever possible and presume that awards will be confirmed.
Wiand v. Schneiderman, 778 F.3d 917 (11th Cir. 2015), citing Brown v. ITT Consumer Financial Corp., 211 F.3d 1217 (11th Cir. 2000): the party seeking vacatur bears a “heavy burden” of proving one of the four exclusive grounds in FAA § 10(a).
Stolt-Nielsen S.A. v. AnimalFeeds International Corp., 559 U.S. 662 (2010), and Major League Baseball Players Association v. Garvey, 532 U.S. 504 (2001): an arbitrator exceeds authority only when he departs from interpreting and applying the agreement and instead “dispense[s] his own brand of industrial justice.” Mere legal or factual errors—even serious ones—do not suffice.
Wiregrass Metal Trades Council AFL-CIO v. Shaw Environmental & Infrastructure, Inc., 837 F.3d 1083 (11th Cir. 2016), and IMC-Agrico Co. v. International Chemical Workers Council, 171 F.3d 1322 (11th Cir. 1999): § 10(a)(4) vacatur is rare because arbitrators’ authority is generally broad; the critical question is whether they arguably performed the task assigned, not whether they did it “correctly.”
Gherardi v. Citigroup Global Markets Inc., 975 F.3d 1232 (11th Cir. 2020): courts do not review the reasoning of arbitration awards for correctness; under § 10(a)(4), the “sole question” is whether the arbitrator was at least arguably doing the job he was empowered to do.
Paladino v. Avnet Computer Technologies, Inc., 134 F.3d 1054 (11th Cir. 1998), and Kahn v. Smith Barney Shearson Inc., 115 F.3d 930 (11th Cir. 1997): these provide examples of when arbitrators have exceeded their authority–e.g., deciding statutory claims not covered by the arbitration agreement, or ignoring preclusive judicial determinations.
Eastern Associated Coal Corp. v. United Mine Workers of America, District 17, 531 U.S. 57 (2000): a court may overturn an award only where the arbitrator acts outside the scope of his authority or issues an award reflecting his own notions of justice, not where the arbitrator simply reaches a result with which the court disagrees.
O.R. Securities, Inc. v. Professional Planning Associates, Inc., 857 F.2d 742 (11th Cir. 1988), and Ultracashmere House, Ltd. v. Meyer, 664 F.2d 1176 (11th Cir. 1981): describing the FAA’s purpose to relieve court congestion and provide a faster, cheaper alternative to litigation—parallel to the NSA’s goals for the IDR process.

These precedents collectively support the Eleventh Circuit’s insistence that court review of NSA IDR determinations is every bit as constrained as review of private commercial arbitration.

D. Fraud in Arbitration — The Bonar Test

To define fraud under FAA § 10(a)(1), the court drew on:

Bonar v. Dean Witter Reynolds, Inc., 835 F.2d 1378 (11th Cir. 1988): to vacate an arbitration award for fraud, the movant must show:
1. The fraud is established by clear and convincing evidence;
2. The fraud could not have been discovered with due diligence before or during the arbitration;
3. The fraud materially related to an issue in the arbitration.

Overlaying this with Rule 9(b)’s pleading requirement, the panel required Reach to allege—with particularity—facts that, if proven, would satisfy each element of the Bonar test. The complaint fell well short.

E. “Undue Means” — Guidance from Other Circuits

The Eleventh Circuit noted that it had never formally defined “undue means” under FAA § 10(a)(1). It turned to other circuits:

American Postal Workers Union v. U.S. Postal Service, 52 F.3d 359 (D.C. Cir. 1995): “undue means” should be limited to misconduct equivalent in seriousness to corruption or fraud, such as physical threats to an arbitrator or other improper influence.
Hoolahan v. IBC Advanced Alloys Corp., 947 F.3d 101 (1st Cir. 2020): similarly construes “undue means” narrowly.
Guardian Flight, L.L.C. v. Medical Evaluators of Texas ASO, L.L.C., 140 F.4th 613 (5th Cir. 2025): a Fifth Circuit decision, particularly notable because it also arises in the air ambulance/NSA space, limiting “undue means” to serious forms of misconduct akin to fraud or corruption.
PaineWebber Group, Inc. v. Zinsmeyer Trusts Partnership, 187 F.3d 988 (8th Cir. 1999): again, “undue means” is confined to misconduct of a similar gravity.

Adopting this general approach, the Eleventh Circuit held that Kaiser’s inconsistent QPA figures—even if misleading—do not rise to the level of “undue means” that might justify vacatur of the arbitration award.

IV. The Court’s Legal Reasoning

A. The NSA–FAA Interface: Importing FAA § 10 Standards

The NSA provision at issue, 42 U.S.C. § 300gg-111(c)(5)(E)(i), provides:

(i) In general. A determination of a certified IDR entity under subparagraph (A)–
(I) shall be 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
(II) 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.

Paragraph (II) explicitly cross-references FAA § 10(a)(1)-(4). Invoking Lorillard, Bragdon, and related precedents, the court held that by importing those paragraphs wholesale, Congress also imported the existing judicial understanding of what those provisions mean.

Reach argued that paragraph (I)—making awards binding “in the absence of a fraudulent claim or evidence of misrepresentation of facts” —implicitly created a separate ground for challenging awards beyond FAA § 10, or at least a distinct cause of action, whenever there is “evidence of misrepresentation.” The district court rejected this, and the Eleventh Circuit agreed with its basic thrust: paragraph (I) addresses when an IDR determination is binding as between the parties, but judicial review remains limited to the grounds in paragraph (II), i.e., FAA § 10(a)(1)-(4).

The panel emphasized that Congress designed the NSA IDR process to be “efficient” and to “minimize costs,” echoing the purposes of the FAA. Expanding judicial review, or creating wide-open misrepresentation-based challenges, would undermine that design by encouraging losing parties to relitigate IDR awards routinely in federal court.

Notably, the court also signaled that even under Reach’s more expansive reading of paragraph (I), the complaint still failed for lack of particularized fraud allegations. Thus, the panel did not need to—and expressly did not—squarely decide whether paragraph (I) creates a separate remedial pathway.

B. Alleged Excess of Authority by the Arbitrator (FAA § 10(a)(4))

Reach claimed that C2C “exceeded its authority” by applying an “illegal presumption” favoring Kaiser’s QPA. Under the NSA, the certified IDR entity must consider:

the QPA; and
additional credible information relating to specified factors (e.g., patient acuity, provider’s quality and training, vehicle type, population density at pickup point, and parties’ good-faith contracting efforts).

According to Reach, C2C in effect treated the QPA as a presumptive benchmark or ceiling, requiring Reach to prove that a “higher OON rate” was warranted, thereby reshaping the statutory scheme in Kaiser’s favor.

The panel rejected this theory at two levels:

Deferential § 10(a)(4) standard. Under Stolt-Nielsen, Sutter, Wiregrass, and Gherardi, courts only ask whether the arbitrator was at least arguably applying the contract/statute and doing the job assigned. They do not second-guess the merits, the evidentiary weighting, or even serious errors. Only where the arbitrator invents his own procedural or substantive rules wholly untethered to the governing law does § 10(a)(4) vacatur become possible.
No plausible factual basis for an “illegal presumption.” The text of C2C’s written determination showed that the arbitrator:
- Identified, almost verbatim, the NSA’s required factors, including the QPA and additional “related and credible information” about quality, acuity, vehicle type, population density, and prior contracting efforts;
- Stated that both parties had submitted such information;
- Concluded that the information “did not support the allowance of payment at a higher OON rate”; and
- Selected Kaiser’s offer as “best represent[ing] the value of the services at issue.”

The language “did not support the allowance of payment at a higher OON rate” simply meant, in context, that Reach’s much higher offer of $52,474.60 was less consistent with the statutory factors than Kaiser’s lower—but still above-QPA—offer, and that the arbitrator chose Kaiser’s offer in baseball-style fashion. The opinion stresses that C2C did not say:

that the QPA was dispositive,
that Reach bore a special burden to justify going above the QPA, or
that the arbitrator would default to the QPA absent special proof.

In short, Reach’s assertion of an “illegal presumption” rested on a strained reading of a single sentence in the award, not on a plausible allegation that C2C deviated from the statutory scheme. Under § 10(a)(4), this falls far short of an excess-of-authority showing.

C. Fraud (FAA § 10(a)(1)) and Rule 9(b)

Reach’s core accusation was that Kaiser committed fraud by representing one QPA figure ($24,813.48) to Reach in the EOB and then representing a different (lower) QPA ($17,304.29) to the arbitrator. Reach alleged that this misled C2C into believing Kaiser’s offer was above QPA and thus more “reasonable.”

The court analyzed this under Bonar and Rule 9(b). It concluded that Reach’s pleadings were deficient in multiple ways.

1. Lack of Particularity: Who, What, When, Where, How

Rule 9(b) requires that a complaint alleging fraud set forth:

Precisely what statements or omissions were made and in what document(s) or oral representations;
The time and place of each statement and the person responsible;
The content of the statements and how they misled the plaintiff; and
What the defendant obtained as a consequence of the fraud.

Applied to Reach’s allegations, the court emphasized:

The complaint said only that Kaiser “represented to REACH that the amount allowed was its QPA for the claim,” without specifying:
- whether this was printed on the EOB itself or in a separate communication,
- who at Kaiser made the representation, and
- the exact content of the representation beyond the paraphrase.
The complaint stated that the EOB was issued on April 21, 2022, but said nothing about where or how the later QPA statement to C2C was made, when exactly it was made (beyond being in the IDR process), or by whom.
The complaint did not concretely explain how the allegedly fraudulent QPA to Reach misled Reach. In fact, Reach admitted that because the purported QPA was “far below reasonable market rates,” it immediately initiated the NSA’s negotiation process—an action inconsistent with being lulled into complacency or misled.
The complaint did not clearly link Kaiser's alleged misstatements to the arbitrator’s decision or specify what Kaiser “obtained” beyond a favorable award, which can be the result of a straightforward merits decision.

As the panel effectively put it, the allegations looked more like a description of inconsistent or opaque pricing practices than a well-pleaded fraud theory.

2. Failure Under the Bonar Fraud Test

Even apart from Rule 9(b), the allegations did not satisfy Bonar’s three-part substantive standard:

Clear and convincing evidence of fraud. The complaint did not provide detailed facts suggesting intentional deception rather than mere internal inconsistency or calculation differences in Kaiser’s QPA reporting.
Non-discoverability with due diligence. Reach did not allege that the “true” QPA, or Kaiser’s internal QPA calculations, could not have been discovered with diligence before or during IDR (for example, via regulatory disclosure requests or IDR submissions).
Material relation to an issue in arbitration. The court saw no non-conclusory allegation that Kaiser’s lower QPA to C2C materially drove C2C’s decision. C2C’s written determination showed that it weighed multiple factors and did not treat the QPA as dispositive.

Without detailed facts showing how these allegedly inconsistent QPA representations changed the outcome—especially in a baseball-style system where Reach’s own offer was far higher than Kaiser’s—Reach could not meet its heavy burden to vacate based on fraud.

D. “Undue Means” (FAA § 10(a)(1))

Reach argued that, even if Kaiser’s conduct did not qualify as “fraud,” it amounted to “undue means” in procuring the award. The court took guidance from other circuits and adopted a narrow view: “undue means” is limited to actions “equivalent in gravity to corruption or fraud,” such as a physical threat to an arbitrator or overt improper influence.

On that understanding, merely submitting a different QPA figure to the arbitrator than to the provider—especially when the arbitrator is expressly permitted to consider and compare all submissions—does not remotely approach the seriousness required. The complaint did not allege:

any threats or coercion directed at the arbitrator,
any illegal side-deals, bribes, or other corruption, or
any concealment of evidence that the arbitrator requested but did not receive.

The court underscored that the IDR’s baseball-style structure itself can explain why Kaiser’s offer prevailed: even if C2C thought the “true” value of the service was somewhere between the two offers (e.g., $30,000 in the opinion’s hypothetical), a very high offer by Reach risks being rejected in favor of a lower, more moderate offer by Kaiser, regardless of the precise QPA level.

E. Naming the IDR Entity as a Defendant

Finally, the court addressed the procedural question of whether an IDR entity like C2C needs to be, or can be, sued directly in order for a court to vacate an IDR determination and remand.

Both sides agreed that if a court were to vacate an IDR award, it has the authority under the NSA to remand the dispute to the IDR entity for a new arbitration. The Eleventh Circuit agreed that naming the arbitrator as a defendant is not necessary to obtain such relief. That conclusion aligns with the general arbitration rule that arbitrators are typically not proper defendants in challenges to awards; the relief runs against the parties, not the neutral decisionmaker.

The court therefore affirmed the dismissal of C2C, without reaching the broader and more controversial question of whether the NSA affirmatively creates a private cause of action against certified IDR entities for damages or injunctive relief. That issue remains open in the Eleventh Circuit.

V. Simplifying Key Legal and Technical Concepts

A. The No Surprises Act and the Role of IDR

The No Surprises Act was enacted to protect patients from “surprise billing”—situations where patients receive care (often in emergencies) from out-of-network providers and then receive huge, unexpected balance bills. For certain emergency and non-emergency services (including air ambulance services), the NSA:

Caps the patient’s cost-sharing obligation at an in-network level;
Forbids providers from balance billing the patient beyond that level; and
Requires providers and plans to resolve the remaining payment dispute between themselves, rather than pushing it to the patient.

To resolve these disputes, the NSA establishes a two-stage process:

Open negotiation period. After an initial payment, the provider and plan attempt to negotiate an agreed amount.
Independent Dispute Resolution (IDR). If negotiation fails, either party may invoke the IDR process, which is a specialized arbitration administered by a certified IDR entity.

The IDR entity conducts “baseball-style” arbitration: each side submits a single offer, and the arbitrator must choose one of those offers—no splitting the difference. This structure is designed to encourage both sides to submit reasonable, good-faith numbers, because extreme positions are more likely to be rejected.

B. What Is the “Qualifying Payment Amount” (QPA)?

The QPA is a central concept in NSA disputes. In simplified terms, it is:

The median of the contracted rates for a particular service in a geographic region that a plan pays to in-network providers.

Under the NSA, the QPA:

Helps determine the patient’s cost-sharing amount; and
Must be considered by the IDR entity as one of several factors when it decides which offer better reflects the value of the service.

The QPA is not supposed to be an absolute cap or a legal presumption of the “correct” rate, but it is an important data point. In this case, Reach alleged that Kaiser used one QPA figure in communications with Reach and a different, lower QPA figure in its IDR submission, allegedly to make its offer look more generous.

C. FAA § 10(a): The Only Grounds for Vacating Arbitration Awards

Under the Federal Arbitration Act, 9 U.S.C. § 10(a), a federal court may vacate an arbitration award only in four circumstances:

Award procured by corruption, fraud, or undue means;
Evident partiality or corruption in the arbitrators;
Arbitrator misconduct (e.g., refusing to postpone a hearing for good cause, refusing to hear pertinent evidence, or other misbehavior prejudicing a party’s rights); or
Arbitrator exceeded his powers or so imperfectly executed them that no definite award was made.

These are exclusive: mere error, unfairness, or disagreement with the result is not enough. The NSA explicitly limits judicial review of IDR determinations to “cases described” in these four paragraphs.

D. Pleading Fraud Under Rule 9(b)

In ordinary civil cases, Rule 8 of the Federal Rules of Civil Procedure requires only a “short and plain statement” showing entitlement to relief. But for fraud (and claims “sounding in fraud”), Rule 9(b) demands much more detail:

Exactly what was said or omitted;
Who said it (or failed to say it);
When and where it was said;
How it was false or misleading and how it misled the plaintiff; and
What the defendant gained as a result.

This level of detail helps protect defendants from baseless accusations of fraudulent behavior—a concern especially acute when a losing party in arbitration seeks to overturn a presumptively final award.

E. “Undue Means” vs. Ordinary Wrongdoing

“Undue means” is a term of art in § 10(a)(1). Courts have interpreted it narrowly, on par with “corruption” or “fraud.” It does not cover every misstatement, mistake, or even bad-faith argument. Rather, it reaches only truly egregious conduct, such as:

Bribing or threatening the arbitrator;
Destroying or falsifying critical evidence to prevent its discovery; or
Conduct that, in practical effect, subverts the entire arbitration process.

By adopting that narrow view, the Eleventh Circuit signaled that “undue means” will not be a catch-all vehicle for disappointed IDR participants to turn ordinary litigation conduct into a ground for vacating awards.

VI. Impact and Significance

A. For Providers and Health Plans: IDR Awards Are Hard to Overturn

For both out-of-network providers (like air ambulance companies) and health plans, the central takeaway is clear: NSA IDR determinations are extremely difficult to vacate in court. The Eleventh Circuit has aligned IDR review with mainstream FAA arbitration doctrine:

Award confirmation is the default; vacatur is the rare exception.
Courts will not revisit the arbitrator’s weighing of the QPA and other statutory factors.
Disagreement with the chosen dollar amount—even where large sums are at stake—does not supply a basis for judicial review.

Practically, this means that:

Providers and plans must treat the IDR proceeding as their one real shot at litigating the merits.
They should not expect to get a second bite at the apple in federal court based on arguments that the arbitrator misapplied the NSA, misunderstood the QPA, or underweighted certain factors.

B. Fraud-Based Challenges Face a Very High Bar

The combination of:

Rule 9(b)’s heightened pleading standard,
the Bonar test for arbitral fraud, and
the narrow interpretation of “undue means”

sets an exceptionally high bar for any party alleging that an IDR award was procured by fraud or misconduct. To succeed, a challenger will need:

Specific, detailed evidence of intentional deceit or corruption;
A clear showing that the deceit could not have been uncovered with reasonable diligence during IDR; and
A strong link between the deceit and the arbitrator’s ultimate choice of offer.

Routine disputes over methodology (e.g., how a QPA was calculated), ambiguous or incomplete explanations on EOBs, or ordinary asymmetries of information are unlikely to satisfy this standard.

C. QPA as One Factor Among Many

The opinion also implicitly reinforces the notion—echoed in regulations and other litigation—that the QPA is only one factor among several in the IDR calculus, not a dispositive benchmark. By quoting C2C’s explanation that it considered:

quality and outcomes;
patient acuity and service complexity;
personnel training and experience;
vehicle type and clinical capability;
population density at the pickup point; and
good-faith contracting efforts over four years,

and by rejecting Reach’s argument that the QPA was improperly treated as presumptive, the Eleventh Circuit gives comfort to arbitrators who follow the statutory list and weigh these factors holistically.

Future challenges predicated on allegations that an arbitrator “over-relied” on the QPA will likely fail unless the award on its face reveals that the arbitrator refused to consider the other mandatory factors.

D. Limited Exposure (For Now) for IDR Entities

The court’s holding that an IDR entity like C2C need not be a named defendant to effectuate vacatur and remand reduces the litigation exposure of IDR administrators. At least in the Eleventh Circuit:

Challenges to IDR awards will typically be framed as actions between providers and plans, not against the arbitrators themselves.
If a court concludes that FAA § 10(a) is satisfied (for example, due to fraud by one party), the remedy will be to vacate and remand, without necessarily imposing liability on the IDR entity.

The panel deliberately left open whether the NSA creates an independent cause of action against IDR entities. But its reasoning and emphasis on the IDR entity’s limited role suggest that future courts may be reluctant to read such a cause of action into the statute absent clear congressional authorization.

E. Strategic Implications for IDR Participants

Given the narrow scope of review and the elevated burden for fraud-based challenges, both providers and plans should consider the following strategies in NSA IDR:

Submit realistic offers. In baseball-style arbitration, extreme offers are risky. The arbitrator will choose the offer that most closely reflects the arbitrator’s own assessment of the “right” value. The opinion’s hypothetical—where Reach’s very high offer loses even if the arbitrator thinks the real value is closer to Reach’s—illustrates this dynamic.
Document statutory factors thoroughly. Because courts will not reweigh the evidence, parties must ensure that the arbitrator has a full record of:
- patient acuity and complexity,
- provider’s outcomes and quality,
- training and capabilities,
- vehicle type and configuration, and
- good-faith contracting history.
Be precise in QPA representations. Although mere inconsistency may not justify vacatur, inconsistent or opaque QPA disclosures can undermine credibility and could become relevant in future cases if coupled with more serious evidence of deception.
Consider regulatory remedies. Disputes about how QPAs are calculated and reported may be more productively addressed through regulatory channels (e.g., CMS oversight, enforcement complaints) than through judicial challenges to particular IDR awards.

F. Doctrinal Significance Beyond the NSA

Beyond the NSA context, REACH Air reinforces several broader principles:

When Congress incorporates existing statutory language, courts presume it incorporates existing case law as well. This presumption of consistent usage and continuity of interpretation has wide application in statutory construction.
Courts remain deeply committed to arbitration finality. Even in highly regulated, statutorily structured arbitration regimes like the NSA IDR process, courts resist expanding the grounds for vacatur or engaging in de facto merits review.
Fraud allegations face substantial procedural and substantive hurdles. The combination of Rule 9(b) and demanding arbitral-fraud standards severely constrains post-award collateral attacks based on alleged misrepresentations.

VII. Conclusion

REACH Air Medical Services LLC v. Kaiser Foundation Health Plan Inc. is a key decision in the emerging body of law around the No Surprises Act’s independent dispute resolution framework. Its core message is straightforward but powerful: NSA IDR awards are to be treated like any other FAA arbitration awards—final, presumptively valid, and subject to only the narrowest judicial review.

The Eleventh Circuit held that:

The NSA’s cross-reference to FAA § 10(a)(1)-(4) imports the full weight of existing FAA jurisprudence, including strict deference to arbitrators and a strong presumption of confirmation.
Allegations that an arbitrator over-valued the QPA, or applied an “illegal presumption,” will not suffice to show that the arbitrator exceeded its authority absent clear evidence that the arbitrator ignored the statutory scheme and applied its own rules.
Fraud-based challenges must meet the stringent pleading requirements of Rule 9(b) and the substantive Bonar standard; generalized accusations about QPA manipulation without detailed, particularized facts are insufficient.
“Undue means” is confined to misconduct equivalent in gravity to corruption or fraud, not to ordinary litigation tactics or inconsistent numbers.
IDR entities like C2C need not be sued directly for a court to vacate an award and remand, and the question whether the NSA creates a cause of action against such entities remains open.

For participants in NSA IDR, the decision underscores that the real battle is the arbitration itself. Once an IDR determination issues, overturning it in federal court will be extraordinarily difficult. For the law more generally, REACH Air stands as a reaffirmation of arbitration finality and a clear signal that Congress’s effort to streamline out-of-network payment disputes will not be undercut by expansive judicial review.