Skip to content
VerdictCONSULTING GROUP

What happens if a health plan does not pay an IDR award?

Verdict Consulting Group Research · Updated

Answer

The statute relies mainly on federal enforcement. Unpaid awards can be reported to the No Surprises Help Desk, and under 42 U.S.C. 300gg-22 HHS may impose civil money penalties of up to $100 per day for each affected individual. Whether a provider can also sue to collect depends on the court: the Fifth and Second Circuits say no.

Detail

The routes that exist

RouteWhat the sources say
Report to the DepartmentsCMS directs parties to the No Surprises Help Desk (1-800-985-3059) to report potential violations of the process
Civil money penalties42 U.S.C. 300gg-22(b)(2)(C) caps HHS penalties at $100 per day for each individual affected by a failure
Private lawsuitDivided: see Can a provider sue to enforce an IDR award?

How courts have weighed the federal route

In dismissing a provider's enforcement suit on August 5, 2026, the Northern District of Illinois treated the Departments' enforcement authority, including penalties, as the remedy Congress chose. Other courts have been skeptical of that route: the same opinion quotes an April 15, 2026 District of Connecticut decision, Agag v. Cigna, which observed that it was "conceivable" a plan could pay the $100-per-day penalty but not a larger IDR award. The District of Maryland, finding a narrow implied right in March 2026, noted that an internal HHS complaint is not an "appeal" of an IDR determination.

Correction (2026-10-10): An earlier version dated the Agag v. Cigna decision to March 2026. The order was issued April 15, 2026.

Read the analysis

Sources

  1. Centers for Medicare & Medicaid Services — About Independent Dispute Resolution ()
  2. Legal Information Institute, Cornell Law School — 42 U.S. Code § 300gg-22 — Enforcement ()
  3. U.S. District Court for the Northern District of Illinois (court filing hosted by the O'Neill Institute) — PHI Health, LLC v. Health Care Service Corp., No. 26 C 2954 (N.D. Ill. Aug. 5, 2026), memorandum opinion and order ()
  4. U.S. District Court for the District of Connecticut (court filing hosted by the O'Neill Institute) — Agag v. Cigna Health and Life Insurance Co., No. 3:25-cv-00498 (D. Conn. Apr. 15, 2026), order on motion to dismiss and cross-motion to confirm ()

General information only, not legal advice. Verdict Consulting Group is not a law firm.