On January 12, the U.S. Supreme Court denied the petition for writ of certiorari in Guardian Flight, leaving in place the Fifth Circuit’s June 2025 decision that we covered in our prior post (available here). As a result, within the Fifth Circuit, providers cannot rely on the No Surprises Act (NSA) itself to enforce Independent Dispute Resolution (IDR) awards in court and face a heightened standing bar for ERISA-based claims where patients are insulated from financial harm. And the persuasive effect of the Fifth Circuit’s holding is bolstered nationwide.

Background
As we explained previously, Guardian Flight arose out of efforts by air ambulance providers Guardian Flight and Med-Trans to collect payments awarded through the IDR process under the NSA. After prevailing in multiple “baseball-style” IDR proceedings against an insurer, the providers alleged that the insurer failed to pay the awards within the 30‑day deadline required by the NSA. They sued to enforce those awards, asserting: (1) direct claims under the NSA; (2) derivative ERISA claims based on assignments from plan beneficiaries; and (3) a Texas quantum meruit claim. The district court dismissed across the board, and the Fifth Circuit affirmed, holding that the NSA does not create a private right of action for providers to enforce IDR awards, that the providers lacked ERISA standing because NSA‑protected beneficiaries suffered no concrete financial injury, and that the quasi‑contract claim failed because the services were rendered for the patients, not for the insurer.

Issues Presented in the Cert Petition
The certiorari petition asked the Supreme Court to review two issues with potentially far‑reaching consequences for NSA and ERISA litigation. First, it asked whether a breach of ERISA plan terms is itself an injury in fact to a plan beneficiary even where the beneficiary is insulated from out‑of‑pocket harm by the NSA’s balance‑billing protections, and therefore whether assignee‑providers can rely on that breach alone to establish Article III standing. Second, it asked whether, when Congress made NSA IDR awards “binding” and directed that insurers “shall” pay them within 30 days, it intended to permit providers to sue in court to enforce those awards, rather than leaving enforcement exclusively to administrative agencies. The petition argued that the Fifth Circuit’s answers to both questions deepen existing splits among the circuits on what constitutes a concrete injury under Spokeo and Ramirez, and on how to read statutory “binding” and “shall pay” language in the private-right-of-action context.

Practical Impact in the Fifth Circuit
With the Supreme Court’s denial of certiorari, the Fifth Circuit’s analysis now firmly governs within Texas, Louisiana, and Mississippi and will be influential elsewhere. In practical terms, providers in the Fifth Circuit cannot bring standalone NSA claims to compel payment of IDR awards, and must instead look primarily to federal and state regulators (such as Health and Human Services) or to contract‑based remedies to address nonpayment. ERISA‑based claims will continue to face heightened standing scrutiny where patients are shielded from financial liability, as the Fifth Circuit treats the plan’s alleged failure to pay as a “technical” breach insufficient, by itself, to constitute a concrete injury to the beneficiary. And state‑law quasi‑contract theories remain constrained by the court’s view that services performed for patients do not satisfy Texas’s requirement that services be rendered for the defendant’s benefit.

Numerous other district courts throughout the United States have followed the Fifth Circuit’s lead in finding providers lack a private right of action to enforce IDR awards, and we expect the denial of certiorari will add further support for district courts considering the issue in the future.